- Email: [email protected]
Bone Health in Preterm Infants: New Nutrient Recommendations
On the Edge
Bone Health in Preterm Infants New Nutrient Recommendations
v
LAURIE LaRUSSO, MS, ELS
Vitamin D is important for preterm infants as well as for full-term infants. However, a poor bone health in preterm infants is primarily due to not enough calcium and phosphorus in the diet. A new American Academy of Pediatrics (AAP) clinical report entitled “Calcium and Vitamin D Requirements of Enterally Fed Preterm Infants,” published in the May 2013 issue of Pediatrics (published online April 29), offers the first dietary recommendations for vitamin D and calcium intakes specifically for preterm infants. Because preterm infants have distinct bone mineral requirements that differ from full-term newborns, pediatricians recommend preterm babies be given 200 to 400 International Units (IU) of vitamin D daily while in the hospital and after being discharged. In addition, preterm infants, especially those with multiple medical problems or who weigh just under 3.5 lbs, are at an increased risk of developing rickets, and should be given calcium and phosphorus supplements or special fortifiers designed for preterm babies. The report concludes that preterm babies need specialized high-mineral diets in the NICU and in some cases after they go home. Such infants should continue to be monitored until they reach a safe body weight. The full report can be found at http://pediatrics.aappublications.org/content/131/5/e1676.full.
Migraine Prevention Drugs in Pregnancy Based on new research from the Neurodevelopmental Effects of Antiepileptic Drugs (NEAD) study, the U.S. Food and Drug Administration (FDA) has reclassified migraine prevention drugs containing valproate from pregnancy category D (benefits outweigh the risks for this use) to pregnancy category X (risks outweigh the benefits for this use). Valproate-containing products include valproate sodium (Depacon), divalproex sodium (Depakote, Depakote CP and Depakote ER), valproic acid (Depakene and Stavzor) and their generics. The final results of the NEAD study showed that children exposed to valproate products in utero had IQ scores at age 6 that were 8 to 11 points lower compared with children who were exposed to other antiepileptic drugs in utero. Valproate products, which already have a boxed warning for fetal risk, including birth defects, are now contraindicated for use in pregnant women. These drugs may still be used to treat bipolar disorder or seizures in pregnant women, if other medications have not controlled the symptoms or are otherwise unacceptable.
http://nwh.awhonn.org
© 2013, AWHONN
275
On the Edge
Hysterectomy and Heart Disease Risk Having a hysterectomy with or without oophorectomy in midlife is unlikely to accelerate a woman’s risk of cardiovascular disease, according to a new study published online May 14th in the Journal of the American College of Cardiology. This finding is contrary to earlier retrospective studies suggesting that hysterectomy in midlife increases a woman’s risk of cardiovascular disease compared with entering menopause naturally. Researchers at the University of Pittsburgh analyzed data from the Study of Women’s Health Across the Nation, which enrolled 3,300 premenopausal women 42 to 52 years of age and not using hormone therapy and followed them annually for 11 years. Data were available for 1,769 women who had reached natural
menopause, 77 women who had a hysterectomy with ovarian conservation and 106 women who had a hysterectomy with bilateral oophorectomy. Annual changes in cardiovascular disease risk factors, including levels of HDL cholesterol, LDL cholesterol, apolipoprotein B, systolic blood pressure, plasminogen activator inhibitor-1 and Factor VIIc and scores on the Homeostasis Model of Assessment-Insulin Resistance (HOMA-IR), did not vary over time between women who had a hysterectomy and women who experienced natural menopause. The few significant differences that were observed between the groups did not indicate increased risk for women who underwent hysterectomy with or without oophorectomy.
Maternal Flu and Bipolar Disorder Risk Laurie LaRusso, MS, ELS, is a freelance medical writer and an adjunct instructor in the Friedman School of Nutrition Science and Policy at Tufts University in Boston. The author reports no conflicts of interest or relevant financial relationships. DOI: 10.1111/1751-486X.12046
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Nursing for Women’s Health
Maternal influenza infection during pregnancy carries a nearly fourfold increased risk of the child developing bipolar disorder in adulthood, according to a new study published online May 8th in JAMA Psychiatry. Earlier studies have hinted at a connection between gestational influenza infection and bipolar disorder in offspring. For this case-control study, a team of researchers examined data from the Child Health and Development Study (CHDS), a birth cohort of more than 19,000 newborns whose pregnant mothers were recruited between 1959 and 1966 from the Kaiser Permanente Medical Care Plan of Northern California. Data from the 92 patients with bipolar disorder confirmed by structured research interviews and consensus diagnosis were compared with data from 722 matched controls from the cohort without bipolar disorder. The nearly fourfold higher risk of bipolar disorder among the adult offspring of mothers exposed to influenza during pregnancy remained after controlling for confounders, such as maternal age, race, educational level, gestational age at birth and maternal psychiatric disorders.
Volume 17
Issue 4
Over-the-Counter Emergency Contraception In April, the FDA approved Plan B One-Step (levonorgestrel) emergency contraception for sale over-the-counter (OTC) to women 15 years of age and older. Previously, the drug had been available by prescription only. A single-dose pill, Plan B One-Step is most effective in reducing the chance of unwanted pregnancy if taken within 3 days after unprotected sexual intercourse. The Plan B two-dose formulation is available OTC to women ages 17 and older and by prescription for those under age 17.
Reducing MRSA Infections in Hospitals According to a study published online May 29 in The New England Journal of Medicine, use of germ-killing soap and ointment on all patients in the intensive care unit (ICU) can reduce bloodstream infections by up to 44 percent and significantly reduce the presence of methicillin-resistant Staphylococcus aureus (MRSA) in ICUs. A team of researchers from University of California, Irvine; Harvard Pilgrim Health Care Institute; Hospital Corporation of America and the Centers for Disease Control and Prevention (CDC) collaborated on the REDUCE MRSA trial, which included nearly 75,000 patients treated in 74 adult ICUs around the United States between 2009 and 2011. Participating hospitals were randomly assigned to one of three MRSA prevention strategies: routine care (i.e., MRSA screening and isolation), targeted decolonization (i.e., germ-killing soap and ointment only for patients with MRSA) and universal decolonization (i.e., germ-killing soap and ointment for all ICU patients). The authors note that the strategy of universal decolonization was both the most effective at preventing hospital-acquired infections, including MRSA, and the easiest to implement because it eliminated the need to screen patients for MRSA.
New Drug for Multiple Sclerosis In March, the FDA approved dimethyl fumarate (Tecfidera) capsules to treat adults with relapsing forms of multiple sclerosis. Because the drug may reduce white blood cell count in some patients, putting them at greater risk for infection, the FDA recommends that health care providers regularly assess white blood cell counts in patients taking Tecfidera.
August | September 2013
Vitamin D and Uterine Fibroids Adequate vitamin D levels in the body may protect against the development of uterine fibroids, according to a new study published in the May issue of the journal Epidemiology. While the active metabolite of vitamin D has been shown to reduce fibroid volume in rats, this is the first study to examine whether vitamin D is related to fibroid status in women. Researchers conducting the National Institute of Environmental Health Sciences Uterine Fibroid Study looked at 1,036 women ages 35 to 49 years living in the Washington, DC, area from 1996 to 1999. The women underwent ultrasounds to determine whether they had fibroids and blood tests to measure their vitamin D levels. In addition, they completed a questionnaire about their sun exposure to assess vitamin D exposure from the sun. The odds of having fibroids were 32 percent lower for women with sufficient blood levels of vitamin D (>20 ng/mL) compared with women whose vitamin D levels were insufficient. Spending more than 1 hour per day outside was associated with 40 percent lower odds of having fibroids compared with less than 1 hour outside each day. The association of vitamin D levels with fibroid risk was similar for both black women and white women. The authors note the consistency of the relationship between vitamin D and fibroids seen in blood levels, sun exposure and across ethnic groups.
Nursing for Women’s Health
277
On the Edge
Endometriosis and BMI Slim women are more likely to develop endometriosis than obese and very obese women, according to a study published online May 14 in the journal Human Reproduction. Researchers from the University of Iowa and Harvard Medical School examined data collected from more than 116,000 female nurses in the Nurses’ Health Study II cohort between September 1989 and June 2011. They compared the body mass index (BMI) and fertility characteristics between the 5,500 women who developed endometriosis during the 20 years of followup and the more than 90,000 women who did not. BMI at age 18 years and current BMI were each inversely associated with endometriosis, such that lower BMI conferred greater risk of endometriosis. These associations were stronger among infertile women. Risk of endometriosis was 39 percent lower in morbidly obese women
(BMI > 40 kg/m2) compared with women in the low-normal range (BMI 18.5 to 22.4 kg/ m2). Obese infertile women with current BMI of 35 to 39.9 kg/m2 and ≥ 40 kg/m2 had 55
BMI at age 18 years and current BMI were each inversely associated with endometriosis, such that lower BMI conferred greater risk of endometriosis percent lower and 62 percent lower risk of endometriosis, respectively, compared with the women with low-normal BMI. The authors caution that having a healthy body weight is not likely a cause of endometriosis, but rather that factors related to infertility, which is more common among obese women, are related to a reduced risk of endometriosis.
Azithromycin and Cardiovascular Risk A study published online May 2 in The New England Journal of Medicine finds that, although a typical 5-day course of azithromycin is associated with increased cardiovascular risk relative to no antibiotic use, this risk is comparable to that observed among patients taking penicillin. Concerns about cardiovascular risks associated with azithromycin were initially raised a year ago when another study in The New England Journal of Medicine reported a small increase in cardiovascular deaths and risk of death from any cause in patients taking azithromycin compared with amoxicillin, ciprofloxacin or not taking any antibiotic. The risk in that study was most pronounced among patients with high baseline cardiovascular risk. In this new study conducted in a nationwide historical cohort of young and middle-age Danish adults (ages 18 to 64 years), researchers linked registry data on filled prescriptions, causes of death and patient characteristics for the period 1997 through 2010. In total, they looked at more than 1 million episodes of azithromycin use and compared it with data on more than 1 million episodes of no antibiotic use and more than 7 million episodes of penicillin V use. Risk of cardiovascular-related death was nearly threefold higher for azithromycin compared with no antibiotic use but comparable to the risk of cardiovascular-related death for penicillin V use.
278
Nursing for Women’s Health
Volume 17
Issue 4
Latest Stats on Listeria Magnesium Sulfate Warning In May, FDA issued a warning advising health care professionals against the continuous administration of magnesium sulfate injection beyond 5 to 7 days to stop preterm labor. New safety data show that this off-label use of the drug beyond 5 to 7 days can lead to low calcium levels and bone problems in the developing fetus. Magnesium sulfate is approved to prevent seizures in preeclampsia and control seizures in eclampsia.
Parental Concerns About HPV Vaccination A new study published online in the May issue of the Journal of Health Care for the Poor and Underserved indicates that low-income and minority parents may be more receptive to human papillomavirus (HPV) vaccination for their daughters than white middleclass parents, who tend to defer the vaccination. Researchers from Boston University interviewed 34 pediatric and family medicine physicians and nurse practitioners who provide primary care, including HPV vaccination in four community health centers in Boston that serve low-income and minority populations, as well as some white and middle-class populations. The providers answered questions about their experiences offering the HPV vaccine and their observations of parental concerns about the vaccine. The major parental concerns about HPV vaccination were safety concerns related to the newness of the vaccine and a preference to postpone vaccination against a sexually transmitted infection in girls they thought were too young to have sex. Providers reported that lowincome and minority parents were more likely to vaccinate, apparently because they tended to follow the provider’s ad-
August | September 2013
vice in general. In particular, they noted that immigrants from Latin America were more inclined to vaccinate their daughters due to their own experiences with vaccine-preventable diseases and cervical cancer in their home countries. Providers also noted that immigrant parents tended to be more realistic about their daughters’ sexual activity than white middle-class parents, even though
Listeria can cause serious infection in certain vulnerable groups, resulting in higher rates of hospitalization and death than most other bacteria commonly spread by contaminated food. According to a new Vital Signs report by the Centers for Disease Control and Prevention, pregnant women are 10 times more likely get listeria infection than the general population, and pregnant Hispanic women are 24 times more likely. The Vital Signs report provides a national snapshot of 2009 to 2011 illness rates and foods associated with listeria outbreaks reported to CDC through three monitoring systems. Key findings include • More than 1,650 listeria illnesses were reported to CDC over a 3-year period. • About 20 percent of infections caused a death. Deaths primarily occurred among older people and as miscarriages or stillbirths. Pregnant women who have listeria infections often have only mild symptoms or fever, but their infections may result in miscarriage, premature labor and serious illness or death in newborn infants. • Over 3 years, 12 outbreaks sickened 224 patients in 38 states. These include the large 2011 outbreak linked to whole cantaloupes from one farm.
providers observed little difference in the sexual behaviors of adolescents from families of different ethnic backgrounds or incomes. Ultimately, the providers reported that few parents decline HPV vaccination outright, but some choose to defer vaccination in younger adolescents until they feel their daughters are closer to becoming sexually active.
• Of the 10 outbreaks with an identified food source, six were linked to soft cheese (mostly Mexican-style cheeses) and two to raw produce (whole cantaloupe and precut celery). To read the full Vital Signs report, visit www.cdc.gov/vitalsigns/listeria/index. html.
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On the Edge
Preventing Postpartum Depression in Adolescent Mothers A study published in the American Journal of Obstetrics and Gynecology has demonstrated that an interpersonal therapy-based intervention program may help reduce rates of postpartum depression among adolescent mothers. Researchers conducted a randomized controlled trial of the effectiveness of an intervention called REACH (Relaxation, Encouragement, Appreciation, Communication, Helpfulness) among 106 pregnant primiparous adolescents up to 17 years old. Half of the women were enrolled in the REACH program and the other half were part of the study’s control group. The REACH program, which was adapted from an interpersonal therapy-based prevention intervention found to reduce postpartum depression in adult women, involves five 1-hour sessions during pregnancy and one postpartum session that includes multimedia, interactive components and homework with feedback. REACH is designed to help girls develop effective communication skills for managing relationship conflicts before and after the baby’s birth, know what to expect from mother-
hood, manage stress, differentiate “baby blues” from depression, develop a support system and healthy relationships and set goals. Postpartum depression was assessed at 6 weeks, 3 months and 6 months postpartum using a structured diagnostic interview. The incidence of depression at 6 months postpartum was 50 percent lower in the REACH group compared with the control group.
Early Test for Gestational Diabetes Risk According to research published in the June issue of the Journal of Clinical Endocrinology & Metabolism, a new blood test given in the first trimester of pregnancy may help predict a woman’s risk for developing gestational diabetes, which typically develops in the second trimester. In a prospective study, Japanese researchers measured blood levels of the soluble (pro)renin receptor, known as s(P)RR, during the first trimester of pregnancy in 716 pregnant women without preexisting diabetes in Tokyo. Forty-four of the women later developed gestational diabetes. Higher levels of s(P)RR in early pregnancy were significantly associated with a higher likelihood of developing gestational diabetes later in pregnancy independent of established or estimated risk factors for the disease. Women who had the highest s(P)RR levels (greater than 34.2 ng/mL) were three times more likely to develop gestational diabetes than women who had the lowest s(P)RR levels (less than 25.8 ng/mL). Random blood glucose levels in the first trimester were in the normal range for the entire cohort and did not differ significantly between women who did and did not develop gestational diabetes. Currently, women at high risk for gestational diabetes typically undergo an oral glucose tolerance test early in pregnancy, whereas low-risk women are not tested until 24 to 28 weeks gestation, when they undergo a 1-hour loading glucose challenge test. This is the first study to demonstrate a significant association between plasma s(P)RR concentrations and the onset of gestational diabetes in pregnant women, which could help predict risk of gestational diabetes regardless of one’s existing risk factors for the disease.
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Volume 17
Issue 4
Cancer Detection With Digital Mammography Of the two types of digital radiography, direct radiography may be better at detecting breast cancer than computed radiography, according to a new study published online May 14 in the journal Radiology. Direct radiography has a detector integrated into the mammographic unit, and the digital image can be read by the system in real time. Computed radiography relies on a cassette-based, removable detector and an external reading device to generate the digital image. Canadian researchers used data on women ages 50 to 74 years who were screened for breast cancer in 2008 and 2009 in the Ontario Breast Screening Program. More than 400,000 women were screened by screen film mammography, approximately 220,000 were screened with direct radiography and nearly 65,000 were screened with computed radiography. During 12 months of follow-up, rates of cancer detection were similar for direct radiography (4.9 per 1,000 mammograms) and screen film mammography (4.8 per 1,000 mammograms) but significantly lower for computed radiography (3.4 per 1,000 mammograms). Computed radiography was 21 percent less likely to detect cancers compared with screen film mammography, even after adjustment for important confounders, including age, initial exam versus rescreening exam and breast density. This is the first study to suggest that computed radiography may have lower cancer detection rates than digital radiography and screen film mammography.
Pelvic Organ Prolapse Surgery The long-term success rates for the gold-standard surgery to treat pelvic organ prolapse are lower than expected, according to a study published in the May 15th issue of JAMA. Researchers at the University of Utah studied 215 women with long-term follow-up in the randomized Colpopexy and Urinary Reduction Efforts (CARE) trial of women with stress continence and symptomatic pelvic organ prolapse who underwent abdominal sacrocolpopexy with or without concomitant anti-incontinence surgery (Burch urethropexy) between 2002 and 2005. Abdominal sacrocolpopexy involves placing a mesh via an abdominal approach to hold the vagina in its correct anatomic position. Nearly one-third of women in the study developed anatomic or symptomatic treatment failure within 5 years after surgery. In addition, about 10 percent of the women experienced mesh erosion by year 7, and two-thirds of these women underwent surgical mesh removal. The authors emphasize that women who undergo sacrocolpopexy need to be educated about symptoms, such as bleeding, discharge or pain, which may be warning signs of mesh or suture erosion. Although having urethropexy prevented stress urinary incontinence longer than not having urethropexy (131 vs. 40 months, respectively), rates of urinary incontinence gradually increased in both treatment groups during 7 years of follow-up.
New Treatment for Ulcerative Colitis In May, the FDA approved golimumab (Simponi) injection to treat adults with moderate to severe ulcerative colitis that is resistant to other treatments or requires continuous steroid therapy. Golimumab is already approved to treat rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis.
August | September 2013
Sugary Drinks and Kidney Stones People with kidney stones are advised to drink more fluids as a way to prevent future stone formation, but sugary drinks should be avoided, according to a new study published in the Clinical Journal of the American Society of Nephrology. Researchers analyzed data from nearly 195,000 participants in three large, ongoing cohort studies: the all-male Health Professionals Follow-Up Study (HPFS) and the all-female Nurses’ Health Study I (NHS I) and Nurses’ Health Study II (NHS II). Participants in these studies answered questionnaires about their beverage consumption and whether they were diagnosed with kidney stones. In total, the analysis included 8 years of follow-up for the HPFS and NHS II cohorts and 13 years for the NHS I cohort. Overall, they found higher risk of stone formation associated with consumption of sugar-sweetened soda and punch and lower risk of stone formation linked to consumption of coffee, tea, beer, wine and orange juice. Participants who drank one or more serving of sugar-sweetened cola per day were at 23 percent higher risk of developing kidney stones compared with those who drank less than one serving per week. Similarly, participants who drank one or more servings of sugar-sweetened noncola beverages per day had a 33 percent higher risk of stone formation. Artificially sweetened sodas were marginally associated with kidney stones (slightly higher risk for noncola drinks and slightly lower risk for cola drinks), but these findings did not reach statistical significance.
Nursing for Women’s Health
281
On the Edge
New Drug for Nausea and Vomiting in Pregnancy In April, the FDA approved the combination drug doxylamine succinate and pyridoxine hydrochloride (Diclegis) to treat nausea and vomiting in pregnant women that has not adequately responded to conservative therapy, such as dietary and lifestyle modifications. Diclegis is an extended-release tablet that must be taken whole on an empty stomach. The recommended starting dose of two tablets at bedtime can be increased to a maximum of four tablets daily (one in the morning, one mid-afternoon and two at bedtime) if symptoms are not adequately controlled.
Hepatitis C Testing
Test Patients Born from 1945 through 1965 for Hepatitis C Ask to be tested
According to a Vital Signs report released in May by the CDC, only half of people who test positive on an initial hepatitis C test receive the necessary follow-up test to determine if their body has cleared the virus or if they are still infected. Infected individuals require treatment for hepatitis C to prevent liver cancer and other serious and potentially deadly consequences of the disease. The full report is available at www.cdc.gov/vitalsigns/pdf/201305-vitalsigns.pdf.
Test patients
Blood test Baby boomers #PSOGSPN UISPVHI
GPSIFQBUJUJT$BOUJCPEZ
Doctors, nurses, and other health care providers
- Negative -
+ Positive +
No hepatitis C virus infection
Follow-up RNA blood test GPSIFQBUJUJT$ WJSVTJOGFDUJPO
/PGVSUIFS BDUJPOOFFEFE
+ Positive +
- Negative -
Hepatitis C virus infection
3FGFSGPS GVSUIFSFWBMVBUJPO
No hepatitis C virus infection
$POOFDUUP NFEJDBMDBSF /PGVSUIFS BDUJPOOFFEFE 33
4063$&$%$VQEBUFEHVJEBODF
H e l p i n g Wo m e n S t a y We l l Today we know more than ever about preventing disease and promoting health. For the very latest, read “Well Woman,” a clinical practice column appearing three times a year in Nursing for Women’s Health. READ IT TO KEEP YOUR PATIENTS—AND YOURSELF—FEELING HEALTHY, ACTIVE AND VIBRANT.
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Nursing for Women’s Health
Volume 17
Issue 4
Bone Health in Preterm Infants New Nutrient Recommendations
v
LAURIE LaRUSSO, MS, ELS
Vitamin D is important for preterm infants as well as for full-term infants. However, a poor bone health in preterm infants is primarily due to not enough calcium and phosphorus in the diet. A new American Academy of Pediatrics (AAP) clinical report entitled “Calcium and Vitamin D Requirements of Enterally Fed Preterm Infants,” published in the May 2013 issue of Pediatrics (published online April 29), offers the first dietary recommendations for vitamin D and calcium intakes specifically for preterm infants. Because preterm infants have distinct bone mineral requirements that differ from full-term newborns, pediatricians recommend preterm babies be given 200 to 400 International Units (IU) of vitamin D daily while in the hospital and after being discharged. In addition, preterm infants, especially those with multiple medical problems or who weigh just under 3.5 lbs, are at an increased risk of developing rickets, and should be given calcium and phosphorus supplements or special fortifiers designed for preterm babies. The report concludes that preterm babies need specialized high-mineral diets in the NICU and in some cases after they go home. Such infants should continue to be monitored until they reach a safe body weight. The full report can be found at http://pediatrics.aappublications.org/content/131/5/e1676.full.
Migraine Prevention Drugs in Pregnancy Based on new research from the Neurodevelopmental Effects of Antiepileptic Drugs (NEAD) study, the U.S. Food and Drug Administration (FDA) has reclassified migraine prevention drugs containing valproate from pregnancy category D (benefits outweigh the risks for this use) to pregnancy category X (risks outweigh the benefits for this use). Valproate-containing products include valproate sodium (Depacon), divalproex sodium (Depakote, Depakote CP and Depakote ER), valproic acid (Depakene and Stavzor) and their generics. The final results of the NEAD study showed that children exposed to valproate products in utero had IQ scores at age 6 that were 8 to 11 points lower compared with children who were exposed to other antiepileptic drugs in utero. Valproate products, which already have a boxed warning for fetal risk, including birth defects, are now contraindicated for use in pregnant women. These drugs may still be used to treat bipolar disorder or seizures in pregnant women, if other medications have not controlled the symptoms or are otherwise unacceptable.
http://nwh.awhonn.org
© 2013, AWHONN
275
On the Edge
Hysterectomy and Heart Disease Risk Having a hysterectomy with or without oophorectomy in midlife is unlikely to accelerate a woman’s risk of cardiovascular disease, according to a new study published online May 14th in the Journal of the American College of Cardiology. This finding is contrary to earlier retrospective studies suggesting that hysterectomy in midlife increases a woman’s risk of cardiovascular disease compared with entering menopause naturally. Researchers at the University of Pittsburgh analyzed data from the Study of Women’s Health Across the Nation, which enrolled 3,300 premenopausal women 42 to 52 years of age and not using hormone therapy and followed them annually for 11 years. Data were available for 1,769 women who had reached natural
menopause, 77 women who had a hysterectomy with ovarian conservation and 106 women who had a hysterectomy with bilateral oophorectomy. Annual changes in cardiovascular disease risk factors, including levels of HDL cholesterol, LDL cholesterol, apolipoprotein B, systolic blood pressure, plasminogen activator inhibitor-1 and Factor VIIc and scores on the Homeostasis Model of Assessment-Insulin Resistance (HOMA-IR), did not vary over time between women who had a hysterectomy and women who experienced natural menopause. The few significant differences that were observed between the groups did not indicate increased risk for women who underwent hysterectomy with or without oophorectomy.
Maternal Flu and Bipolar Disorder Risk Laurie LaRusso, MS, ELS, is a freelance medical writer and an adjunct instructor in the Friedman School of Nutrition Science and Policy at Tufts University in Boston. The author reports no conflicts of interest or relevant financial relationships. DOI: 10.1111/1751-486X.12046
276
Nursing for Women’s Health
Maternal influenza infection during pregnancy carries a nearly fourfold increased risk of the child developing bipolar disorder in adulthood, according to a new study published online May 8th in JAMA Psychiatry. Earlier studies have hinted at a connection between gestational influenza infection and bipolar disorder in offspring. For this case-control study, a team of researchers examined data from the Child Health and Development Study (CHDS), a birth cohort of more than 19,000 newborns whose pregnant mothers were recruited between 1959 and 1966 from the Kaiser Permanente Medical Care Plan of Northern California. Data from the 92 patients with bipolar disorder confirmed by structured research interviews and consensus diagnosis were compared with data from 722 matched controls from the cohort without bipolar disorder. The nearly fourfold higher risk of bipolar disorder among the adult offspring of mothers exposed to influenza during pregnancy remained after controlling for confounders, such as maternal age, race, educational level, gestational age at birth and maternal psychiatric disorders.
Volume 17
Issue 4
Over-the-Counter Emergency Contraception In April, the FDA approved Plan B One-Step (levonorgestrel) emergency contraception for sale over-the-counter (OTC) to women 15 years of age and older. Previously, the drug had been available by prescription only. A single-dose pill, Plan B One-Step is most effective in reducing the chance of unwanted pregnancy if taken within 3 days after unprotected sexual intercourse. The Plan B two-dose formulation is available OTC to women ages 17 and older and by prescription for those under age 17.
Reducing MRSA Infections in Hospitals According to a study published online May 29 in The New England Journal of Medicine, use of germ-killing soap and ointment on all patients in the intensive care unit (ICU) can reduce bloodstream infections by up to 44 percent and significantly reduce the presence of methicillin-resistant Staphylococcus aureus (MRSA) in ICUs. A team of researchers from University of California, Irvine; Harvard Pilgrim Health Care Institute; Hospital Corporation of America and the Centers for Disease Control and Prevention (CDC) collaborated on the REDUCE MRSA trial, which included nearly 75,000 patients treated in 74 adult ICUs around the United States between 2009 and 2011. Participating hospitals were randomly assigned to one of three MRSA prevention strategies: routine care (i.e., MRSA screening and isolation), targeted decolonization (i.e., germ-killing soap and ointment only for patients with MRSA) and universal decolonization (i.e., germ-killing soap and ointment for all ICU patients). The authors note that the strategy of universal decolonization was both the most effective at preventing hospital-acquired infections, including MRSA, and the easiest to implement because it eliminated the need to screen patients for MRSA.
New Drug for Multiple Sclerosis In March, the FDA approved dimethyl fumarate (Tecfidera) capsules to treat adults with relapsing forms of multiple sclerosis. Because the drug may reduce white blood cell count in some patients, putting them at greater risk for infection, the FDA recommends that health care providers regularly assess white blood cell counts in patients taking Tecfidera.
August | September 2013
Vitamin D and Uterine Fibroids Adequate vitamin D levels in the body may protect against the development of uterine fibroids, according to a new study published in the May issue of the journal Epidemiology. While the active metabolite of vitamin D has been shown to reduce fibroid volume in rats, this is the first study to examine whether vitamin D is related to fibroid status in women. Researchers conducting the National Institute of Environmental Health Sciences Uterine Fibroid Study looked at 1,036 women ages 35 to 49 years living in the Washington, DC, area from 1996 to 1999. The women underwent ultrasounds to determine whether they had fibroids and blood tests to measure their vitamin D levels. In addition, they completed a questionnaire about their sun exposure to assess vitamin D exposure from the sun. The odds of having fibroids were 32 percent lower for women with sufficient blood levels of vitamin D (>20 ng/mL) compared with women whose vitamin D levels were insufficient. Spending more than 1 hour per day outside was associated with 40 percent lower odds of having fibroids compared with less than 1 hour outside each day. The association of vitamin D levels with fibroid risk was similar for both black women and white women. The authors note the consistency of the relationship between vitamin D and fibroids seen in blood levels, sun exposure and across ethnic groups.
Nursing for Women’s Health
277
On the Edge
Endometriosis and BMI Slim women are more likely to develop endometriosis than obese and very obese women, according to a study published online May 14 in the journal Human Reproduction. Researchers from the University of Iowa and Harvard Medical School examined data collected from more than 116,000 female nurses in the Nurses’ Health Study II cohort between September 1989 and June 2011. They compared the body mass index (BMI) and fertility characteristics between the 5,500 women who developed endometriosis during the 20 years of followup and the more than 90,000 women who did not. BMI at age 18 years and current BMI were each inversely associated with endometriosis, such that lower BMI conferred greater risk of endometriosis. These associations were stronger among infertile women. Risk of endometriosis was 39 percent lower in morbidly obese women
(BMI > 40 kg/m2) compared with women in the low-normal range (BMI 18.5 to 22.4 kg/ m2). Obese infertile women with current BMI of 35 to 39.9 kg/m2 and ≥ 40 kg/m2 had 55
BMI at age 18 years and current BMI were each inversely associated with endometriosis, such that lower BMI conferred greater risk of endometriosis percent lower and 62 percent lower risk of endometriosis, respectively, compared with the women with low-normal BMI. The authors caution that having a healthy body weight is not likely a cause of endometriosis, but rather that factors related to infertility, which is more common among obese women, are related to a reduced risk of endometriosis.
Azithromycin and Cardiovascular Risk A study published online May 2 in The New England Journal of Medicine finds that, although a typical 5-day course of azithromycin is associated with increased cardiovascular risk relative to no antibiotic use, this risk is comparable to that observed among patients taking penicillin. Concerns about cardiovascular risks associated with azithromycin were initially raised a year ago when another study in The New England Journal of Medicine reported a small increase in cardiovascular deaths and risk of death from any cause in patients taking azithromycin compared with amoxicillin, ciprofloxacin or not taking any antibiotic. The risk in that study was most pronounced among patients with high baseline cardiovascular risk. In this new study conducted in a nationwide historical cohort of young and middle-age Danish adults (ages 18 to 64 years), researchers linked registry data on filled prescriptions, causes of death and patient characteristics for the period 1997 through 2010. In total, they looked at more than 1 million episodes of azithromycin use and compared it with data on more than 1 million episodes of no antibiotic use and more than 7 million episodes of penicillin V use. Risk of cardiovascular-related death was nearly threefold higher for azithromycin compared with no antibiotic use but comparable to the risk of cardiovascular-related death for penicillin V use.
278
Nursing for Women’s Health
Volume 17
Issue 4
Latest Stats on Listeria Magnesium Sulfate Warning In May, FDA issued a warning advising health care professionals against the continuous administration of magnesium sulfate injection beyond 5 to 7 days to stop preterm labor. New safety data show that this off-label use of the drug beyond 5 to 7 days can lead to low calcium levels and bone problems in the developing fetus. Magnesium sulfate is approved to prevent seizures in preeclampsia and control seizures in eclampsia.
Parental Concerns About HPV Vaccination A new study published online in the May issue of the Journal of Health Care for the Poor and Underserved indicates that low-income and minority parents may be more receptive to human papillomavirus (HPV) vaccination for their daughters than white middleclass parents, who tend to defer the vaccination. Researchers from Boston University interviewed 34 pediatric and family medicine physicians and nurse practitioners who provide primary care, including HPV vaccination in four community health centers in Boston that serve low-income and minority populations, as well as some white and middle-class populations. The providers answered questions about their experiences offering the HPV vaccine and their observations of parental concerns about the vaccine. The major parental concerns about HPV vaccination were safety concerns related to the newness of the vaccine and a preference to postpone vaccination against a sexually transmitted infection in girls they thought were too young to have sex. Providers reported that lowincome and minority parents were more likely to vaccinate, apparently because they tended to follow the provider’s ad-
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vice in general. In particular, they noted that immigrants from Latin America were more inclined to vaccinate their daughters due to their own experiences with vaccine-preventable diseases and cervical cancer in their home countries. Providers also noted that immigrant parents tended to be more realistic about their daughters’ sexual activity than white middle-class parents, even though
Listeria can cause serious infection in certain vulnerable groups, resulting in higher rates of hospitalization and death than most other bacteria commonly spread by contaminated food. According to a new Vital Signs report by the Centers for Disease Control and Prevention, pregnant women are 10 times more likely get listeria infection than the general population, and pregnant Hispanic women are 24 times more likely. The Vital Signs report provides a national snapshot of 2009 to 2011 illness rates and foods associated with listeria outbreaks reported to CDC through three monitoring systems. Key findings include • More than 1,650 listeria illnesses were reported to CDC over a 3-year period. • About 20 percent of infections caused a death. Deaths primarily occurred among older people and as miscarriages or stillbirths. Pregnant women who have listeria infections often have only mild symptoms or fever, but their infections may result in miscarriage, premature labor and serious illness or death in newborn infants. • Over 3 years, 12 outbreaks sickened 224 patients in 38 states. These include the large 2011 outbreak linked to whole cantaloupes from one farm.
providers observed little difference in the sexual behaviors of adolescents from families of different ethnic backgrounds or incomes. Ultimately, the providers reported that few parents decline HPV vaccination outright, but some choose to defer vaccination in younger adolescents until they feel their daughters are closer to becoming sexually active.
• Of the 10 outbreaks with an identified food source, six were linked to soft cheese (mostly Mexican-style cheeses) and two to raw produce (whole cantaloupe and precut celery). To read the full Vital Signs report, visit www.cdc.gov/vitalsigns/listeria/index. html.
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Preventing Postpartum Depression in Adolescent Mothers A study published in the American Journal of Obstetrics and Gynecology has demonstrated that an interpersonal therapy-based intervention program may help reduce rates of postpartum depression among adolescent mothers. Researchers conducted a randomized controlled trial of the effectiveness of an intervention called REACH (Relaxation, Encouragement, Appreciation, Communication, Helpfulness) among 106 pregnant primiparous adolescents up to 17 years old. Half of the women were enrolled in the REACH program and the other half were part of the study’s control group. The REACH program, which was adapted from an interpersonal therapy-based prevention intervention found to reduce postpartum depression in adult women, involves five 1-hour sessions during pregnancy and one postpartum session that includes multimedia, interactive components and homework with feedback. REACH is designed to help girls develop effective communication skills for managing relationship conflicts before and after the baby’s birth, know what to expect from mother-
hood, manage stress, differentiate “baby blues” from depression, develop a support system and healthy relationships and set goals. Postpartum depression was assessed at 6 weeks, 3 months and 6 months postpartum using a structured diagnostic interview. The incidence of depression at 6 months postpartum was 50 percent lower in the REACH group compared with the control group.
Early Test for Gestational Diabetes Risk According to research published in the June issue of the Journal of Clinical Endocrinology & Metabolism, a new blood test given in the first trimester of pregnancy may help predict a woman’s risk for developing gestational diabetes, which typically develops in the second trimester. In a prospective study, Japanese researchers measured blood levels of the soluble (pro)renin receptor, known as s(P)RR, during the first trimester of pregnancy in 716 pregnant women without preexisting diabetes in Tokyo. Forty-four of the women later developed gestational diabetes. Higher levels of s(P)RR in early pregnancy were significantly associated with a higher likelihood of developing gestational diabetes later in pregnancy independent of established or estimated risk factors for the disease. Women who had the highest s(P)RR levels (greater than 34.2 ng/mL) were three times more likely to develop gestational diabetes than women who had the lowest s(P)RR levels (less than 25.8 ng/mL). Random blood glucose levels in the first trimester were in the normal range for the entire cohort and did not differ significantly between women who did and did not develop gestational diabetes. Currently, women at high risk for gestational diabetes typically undergo an oral glucose tolerance test early in pregnancy, whereas low-risk women are not tested until 24 to 28 weeks gestation, when they undergo a 1-hour loading glucose challenge test. This is the first study to demonstrate a significant association between plasma s(P)RR concentrations and the onset of gestational diabetes in pregnant women, which could help predict risk of gestational diabetes regardless of one’s existing risk factors for the disease.
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Cancer Detection With Digital Mammography Of the two types of digital radiography, direct radiography may be better at detecting breast cancer than computed radiography, according to a new study published online May 14 in the journal Radiology. Direct radiography has a detector integrated into the mammographic unit, and the digital image can be read by the system in real time. Computed radiography relies on a cassette-based, removable detector and an external reading device to generate the digital image. Canadian researchers used data on women ages 50 to 74 years who were screened for breast cancer in 2008 and 2009 in the Ontario Breast Screening Program. More than 400,000 women were screened by screen film mammography, approximately 220,000 were screened with direct radiography and nearly 65,000 were screened with computed radiography. During 12 months of follow-up, rates of cancer detection were similar for direct radiography (4.9 per 1,000 mammograms) and screen film mammography (4.8 per 1,000 mammograms) but significantly lower for computed radiography (3.4 per 1,000 mammograms). Computed radiography was 21 percent less likely to detect cancers compared with screen film mammography, even after adjustment for important confounders, including age, initial exam versus rescreening exam and breast density. This is the first study to suggest that computed radiography may have lower cancer detection rates than digital radiography and screen film mammography.
Pelvic Organ Prolapse Surgery The long-term success rates for the gold-standard surgery to treat pelvic organ prolapse are lower than expected, according to a study published in the May 15th issue of JAMA. Researchers at the University of Utah studied 215 women with long-term follow-up in the randomized Colpopexy and Urinary Reduction Efforts (CARE) trial of women with stress continence and symptomatic pelvic organ prolapse who underwent abdominal sacrocolpopexy with or without concomitant anti-incontinence surgery (Burch urethropexy) between 2002 and 2005. Abdominal sacrocolpopexy involves placing a mesh via an abdominal approach to hold the vagina in its correct anatomic position. Nearly one-third of women in the study developed anatomic or symptomatic treatment failure within 5 years after surgery. In addition, about 10 percent of the women experienced mesh erosion by year 7, and two-thirds of these women underwent surgical mesh removal. The authors emphasize that women who undergo sacrocolpopexy need to be educated about symptoms, such as bleeding, discharge or pain, which may be warning signs of mesh or suture erosion. Although having urethropexy prevented stress urinary incontinence longer than not having urethropexy (131 vs. 40 months, respectively), rates of urinary incontinence gradually increased in both treatment groups during 7 years of follow-up.
New Treatment for Ulcerative Colitis In May, the FDA approved golimumab (Simponi) injection to treat adults with moderate to severe ulcerative colitis that is resistant to other treatments or requires continuous steroid therapy. Golimumab is already approved to treat rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis.
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Sugary Drinks and Kidney Stones People with kidney stones are advised to drink more fluids as a way to prevent future stone formation, but sugary drinks should be avoided, according to a new study published in the Clinical Journal of the American Society of Nephrology. Researchers analyzed data from nearly 195,000 participants in three large, ongoing cohort studies: the all-male Health Professionals Follow-Up Study (HPFS) and the all-female Nurses’ Health Study I (NHS I) and Nurses’ Health Study II (NHS II). Participants in these studies answered questionnaires about their beverage consumption and whether they were diagnosed with kidney stones. In total, the analysis included 8 years of follow-up for the HPFS and NHS II cohorts and 13 years for the NHS I cohort. Overall, they found higher risk of stone formation associated with consumption of sugar-sweetened soda and punch and lower risk of stone formation linked to consumption of coffee, tea, beer, wine and orange juice. Participants who drank one or more serving of sugar-sweetened cola per day were at 23 percent higher risk of developing kidney stones compared with those who drank less than one serving per week. Similarly, participants who drank one or more servings of sugar-sweetened noncola beverages per day had a 33 percent higher risk of stone formation. Artificially sweetened sodas were marginally associated with kidney stones (slightly higher risk for noncola drinks and slightly lower risk for cola drinks), but these findings did not reach statistical significance.
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New Drug for Nausea and Vomiting in Pregnancy In April, the FDA approved the combination drug doxylamine succinate and pyridoxine hydrochloride (Diclegis) to treat nausea and vomiting in pregnant women that has not adequately responded to conservative therapy, such as dietary and lifestyle modifications. Diclegis is an extended-release tablet that must be taken whole on an empty stomach. The recommended starting dose of two tablets at bedtime can be increased to a maximum of four tablets daily (one in the morning, one mid-afternoon and two at bedtime) if symptoms are not adequately controlled.
Hepatitis C Testing
Test Patients Born from 1945 through 1965 for Hepatitis C Ask to be tested
According to a Vital Signs report released in May by the CDC, only half of people who test positive on an initial hepatitis C test receive the necessary follow-up test to determine if their body has cleared the virus or if they are still infected. Infected individuals require treatment for hepatitis C to prevent liver cancer and other serious and potentially deadly consequences of the disease. The full report is available at www.cdc.gov/vitalsigns/pdf/201305-vitalsigns.pdf.
Test patients
Blood test Baby boomers #PSOGSPN UISPVHI
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Doctors, nurses, and other health care providers
- Negative -
+ Positive +
No hepatitis C virus infection
Follow-up RNA blood test GPSIFQBUJUJT$ WJSVTJOGFDUJPO
/PGVSUIFS BDUJPOOFFEFE
+ Positive +
- Negative -
Hepatitis C virus infection
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No hepatitis C virus infection
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4063$&$%$VQEBUFEHVJEBODF
H e l p i n g Wo m e n S t a y We l l Today we know more than ever about preventing disease and promoting health. For the very latest, read “Well Woman,” a clinical practice column appearing three times a year in Nursing for Women’s Health. READ IT TO KEEP YOUR PATIENTS—AND YOURSELF—FEELING HEALTHY, ACTIVE AND VIBRANT.
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