“We are what we eat” is an old chestnut.
The journals are full of articles on how diets affect risk of disease and, with the prevalence of obesity at an all-time high, there is no lack of publications on diets that affect weight. The dangers of being overweight in pregnancy are well documented and the review by Catalano (see summary) highlights these.
Those wishing to supplement their diets with healthy additives should do so with caution. More is not necessarily better and the antioxidant story is sobering.
Pregnant women's intake is also revealing and the article on the dangers of eating fish is a real “myth-buster”.
Also in the life-style paradigm, sex is enjoying a greater press with the tensions between medicalising sexual function and suppressing information receiving attention. What is normal function and what is dysfunction?
You decide how much is enough of what!
03 April, 2007
05 March, 2007
Density or detection in breast cancer
Radiologically, the breast varies according to its tissue composition. Fat is radiographically translucent and appears dark on the film. Epithelium and stroma are radiographically opaque or dense and appear light on the film. The amount of radio-opaque tissue is referred to as the breast's density and generally the higher a woman's breast density, the greater her risk of developing breast cancer.
As well as the increased risk, high breast density makes the interpretation of mammography films more difficult, so early lesions may go undetected, leading to poorer outcomes. It is difficult to say whether it is the breast density per se which increases the risk or the delay in diagnosis because of the density which is the problem.
In an attempt to resolve the issue, Boyd et al from Canada (NEJM 2007;356:227-36) noted the woman's breast density at her first mammography and then carefully tracked her risk of subsequent cancer using modern techniques. Thus they hoped to eliminate the detection problem and quantify the risk of high density breast tissue. Their results were conclusive in that women with densities over 75% were five times more likely to develop breast cancer than those with densities below 10%.
Kerlikowske in an editorial (pp 297-9) draws these data together with other risk factors, such as age, family history, BRCA status, and makes a plea for defining each woman's risk status and advise her about mammography accordingly. The density factor is a major risk and seems especially important in women aged 50 to 55 years. Better detection methods, possibly with digital as opposed to film screening may help but the bottom line remains - the greater the breast density, the greater the risk.
As well as the increased risk, high breast density makes the interpretation of mammography films more difficult, so early lesions may go undetected, leading to poorer outcomes. It is difficult to say whether it is the breast density per se which increases the risk or the delay in diagnosis because of the density which is the problem.
In an attempt to resolve the issue, Boyd et al from Canada (NEJM 2007;356:227-36) noted the woman's breast density at her first mammography and then carefully tracked her risk of subsequent cancer using modern techniques. Thus they hoped to eliminate the detection problem and quantify the risk of high density breast tissue. Their results were conclusive in that women with densities over 75% were five times more likely to develop breast cancer than those with densities below 10%.
Kerlikowske in an editorial (pp 297-9) draws these data together with other risk factors, such as age, family history, BRCA status, and makes a plea for defining each woman's risk status and advise her about mammography accordingly. The density factor is a major risk and seems especially important in women aged 50 to 55 years. Better detection methods, possibly with digital as opposed to film screening may help but the bottom line remains - the greater the breast density, the greater the risk.
The latest JASS is out
The medical journals are changing. The BMJ looks more like Time magazine than a medical journal with attention-grabbing coloured text and photos. The American Journal of O&G has reduced itself to summaries-only for the paper version, leaving subscribers to go to the electronic version for the full text.
The content is changing too with summaries from other journals, Cochrane abstracts in Obstets Gynecol, as well as articles on politics, prostitutes and sexual behaviour. These changes may be responses to the challenge of information technology with the delivery of data via the internet or podcasts. It seems even television is threatened by the popularity of mobile phones, iPods, SMS and personal communication networks. If you don't believe this - ask your children!
There really does seem to be an honest move away from the stereotyped medical journalism of the last century and certainly the journals' willingness to prod the establishment on moral matters seems healthy to JASS.
All of this competition for attention means more work for JASS to distill the wisdom from the razzamatazz.
With pleasure.
Remember, what you see on this blog is just a sample of the full JASS you can receive by going to the website and subscribing.
The content is changing too with summaries from other journals, Cochrane abstracts in Obstets Gynecol, as well as articles on politics, prostitutes and sexual behaviour. These changes may be responses to the challenge of information technology with the delivery of data via the internet or podcasts. It seems even television is threatened by the popularity of mobile phones, iPods, SMS and personal communication networks. If you don't believe this - ask your children!
There really does seem to be an honest move away from the stereotyped medical journalism of the last century and certainly the journals' willingness to prod the establishment on moral matters seems healthy to JASS.
All of this competition for attention means more work for JASS to distill the wisdom from the razzamatazz.
With pleasure.
Remember, what you see on this blog is just a sample of the full JASS you can receive by going to the website and subscribing.
14 February, 2007
SIDS
The sudden infant death syndrome (SIDS) is the leading cause of infant mortality in developed countries. The risk is greatest in the first six months of life while the autonomic nervous system matures to control the homeostatic functions of respiratory drive, blood pressure regulation, temperature, airway reflexes and arousal. It appears that the functioning of these mechanisms requires serotonin (5 hydroxytryptamine 5HT) to be normally produced, released and cleared in the region of the medulla and brain stem. Where this is not achieved, the risk of SIDS rises, as found in post-mortem demonstrations of excess 5HT by a Californian group led by Paterson (JAMA 2006;296:2134-32).
They showed that 5HT dysregulation was a neuro-chemical abnormality far more frequently found in SIDS victims than controls which may explain an underlying vulnerability and partially explain the male predisposition. Wease-Mayer in an editorial (pp 2143-4) alludes to the preventable factors in SIDS, namely putting all children to sleep on their backs on firm surfaces, avoiding soft bedding and overheating, as well as reducing exposure to antenatal or postnatal smoking. It was found in a recent US survey that two-thirds of children succumbing to SIDS were sleeping prone when they died, so it is time to re-launch the “Back-to-Sleep” campaign.
They showed that 5HT dysregulation was a neuro-chemical abnormality far more frequently found in SIDS victims than controls which may explain an underlying vulnerability and partially explain the male predisposition. Wease-Mayer in an editorial (pp 2143-4) alludes to the preventable factors in SIDS, namely putting all children to sleep on their backs on firm surfaces, avoiding soft bedding and overheating, as well as reducing exposure to antenatal or postnatal smoking. It was found in a recent US survey that two-thirds of children succumbing to SIDS were sleeping prone when they died, so it is time to re-launch the “Back-to-Sleep” campaign.
26 January, 2007
25 January, 2007
Breast feeding and intelligence
There are many advantages to breast feeding - to mother and baby. These include the effect of colostrum on immunity, fewer diarrhoeal diseases, the benefits of omega 3 fatty acids on visual developments in small infants, as well as improved bonding and less breast diseases later. It remains unclear whether the child's intelligence is affected by breast feeding, although it remains an unequaled way of providing ideal nutrition.
To look at the effect of breast feeing on IQ, Der et al defined the known variables in over 5 000 children and teased out factors such as education, race, wealth, smoking, birth order, birth weight and home environment (BMJ 2006;333:945-8). In general, breast-fed babies scored four points higher in testing than formula-fed infants, but almost all this effect was attributable to the mother's IQ. In other words, inheriting the mother's cognitive abilities was more important than being fed her breast milk as measured by intelligence tests.
These findings can be used to reassure mothers who cannot breast feed, but in no way detract from the many other plus factors which should persuade as many women to breast feed as possible for at least six months.
To look at the effect of breast feeing on IQ, Der et al defined the known variables in over 5 000 children and teased out factors such as education, race, wealth, smoking, birth order, birth weight and home environment (BMJ 2006;333:945-8). In general, breast-fed babies scored four points higher in testing than formula-fed infants, but almost all this effect was attributable to the mother's IQ. In other words, inheriting the mother's cognitive abilities was more important than being fed her breast milk as measured by intelligence tests.
These findings can be used to reassure mothers who cannot breast feed, but in no way detract from the many other plus factors which should persuade as many women to breast feed as possible for at least six months.
15 January, 2007
Chemotherapy for breast cancer
Thirty years ago, Bonadonna and his colleagues proved that adjuvant chemotherapy made a difference to survival following initial surgery in women with early breast cancer (Levine & Whelan NEJM 2006;355:1920-2). The original agents, cyclophosphamide, methotrexate and flurouracil (CMF) have been the gold standard against which newer drugs are assessed.
There have been numerous trials of chemotherapy mainly studying anthracyclines and taxanes in various combinations which are of interest to oncologists, but gynaecologists and GPs need to know that:
* adjunct postoperative chemotherapy has a modest benefit on survival
* it has considerable toxicity and is expensive
* its use is determined by the risk of recurrence which in turn depends on tumour size, axillary node status and pathology grade
* receptor status for human epidermal growth factor (HER2) and treatment with trastuzumab is a promising development
* oestrogen receptor status and hormonal treatment with tamoxifen greatly reduces recurrence.
Trials like that of Poole et al (pp 1851-62) will continue to refine the best combination of agents but the next major step forward will be the use of microarray techniques to identify each tumour's gene profile and then tailor the therapy individually.
There have been numerous trials of chemotherapy mainly studying anthracyclines and taxanes in various combinations which are of interest to oncologists, but gynaecologists and GPs need to know that:
* adjunct postoperative chemotherapy has a modest benefit on survival
* it has considerable toxicity and is expensive
* its use is determined by the risk of recurrence which in turn depends on tumour size, axillary node status and pathology grade
* receptor status for human epidermal growth factor (HER2) and treatment with trastuzumab is a promising development
* oestrogen receptor status and hormonal treatment with tamoxifen greatly reduces recurrence.
Trials like that of Poole et al (pp 1851-62) will continue to refine the best combination of agents but the next major step forward will be the use of microarray techniques to identify each tumour's gene profile and then tailor the therapy individually.
05 January, 2007
December JASS out
JASS started in early 1997 so this is our tenth birthday.
It has gone from strength to strength and is now subscribed to in 44 countries.
We thank you for your support and will be offering even better opportunities in 2007. May we remind you that if you belong to an academic institution you may wish to enquire about our corporate subscription rates which allow for onward distribution to staff at attractive rates.
The year ends with global concerns about the lack of progress in women's health in developing nations and generally the ever-widening gap between the haves and the have-nots. The have-nots get the worst deals from the pharmaceutical industry, bear the largest burden of disease with the fewest resources, lose their health care workers to richer countries and seen to have less wise leadership.
Perhaps the new WHO leadership under Dr Chan from China will make a difference.
For those wishing JASS to supply CPD certificates, please complete the 2006 Annual Answer Sheet for the year and send it to us for review and points allocation.
We wish you good health personally from Team JASS and a peaceful New Year.
It has gone from strength to strength and is now subscribed to in 44 countries.
We thank you for your support and will be offering even better opportunities in 2007. May we remind you that if you belong to an academic institution you may wish to enquire about our corporate subscription rates which allow for onward distribution to staff at attractive rates.
The year ends with global concerns about the lack of progress in women's health in developing nations and generally the ever-widening gap between the haves and the have-nots. The have-nots get the worst deals from the pharmaceutical industry, bear the largest burden of disease with the fewest resources, lose their health care workers to richer countries and seen to have less wise leadership.
Perhaps the new WHO leadership under Dr Chan from China will make a difference.
For those wishing JASS to supply CPD certificates, please complete the 2006 Annual Answer Sheet for the year and send it to us for review and points allocation.
We wish you good health personally from Team JASS and a peaceful New Year.
22 December, 2006
Cerebral palsy and obstetrics
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).
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).
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.
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