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C-section raises hysterectomy complication risk later
Women who have at least one cesarean delivery have a more than 30% risk of a complication requiring reoperation after benign hysterectomy later in life, compared with women who have had vaginal deliveries only, according to a study of more than 7,600 women in a Danish patient registry.
Cesarean delivery is the most common major surgery performed in the world, and the rate is rapidly increasing, with the global average cesarean rate estimated at 18.6%, and rates as high as 52% in some European countries. However, the impact cesarean deliveries have on surgical complications later in life has not been thoroughly studied. The study authors said this might be the first population study of the association of cesarean delivery with hysterectomy complications.
Of the 388 women (5%) who had a hysterectomy and then a reoperation within 30 days, the risk increased with the number of previous cesarean deliveries. Those who had vaginal-only deliveries had reoperation rates of 4.4%, compared with 6.2% for those who had one cesarean delivery and 6.8% for those who had two or more. That represents increased risks of 31% and 35% for women who had one cesarean delivery and two or more cesarean deliveries, respectively, compared with women who had only vaginal deliveries.
Likewise, surgical complications were 16% more frequent in women who had one previous cesarean delivery and 30% more likely in women with two or more cesarean deliveries. Women who had two or more cesarean deliveries were almost twice as likely (odds ratio, 1.93) to receive a blood transfusion.
“Our results imply that information on long-term associations should be made more readily available to women, clinicians, and policymakers and suggest that decisions on cesarean delivery should take into account not only immediate maternal and neonatal influences, but also women’s health in the long term, including an increased risk of reoperation and complications associated with surgery later in life,” the researchers wrote. “The results support policies and clinical efforts to prevent cesarean deliveries that are not medically indicated.”
The study noted some limitations, including the observational design, which did not allow for elimination of all potential confounding factors.
The researchers reported having no relevant financial disclosures.
Women who have at least one cesarean delivery have a more than 30% risk of a complication requiring reoperation after benign hysterectomy later in life, compared with women who have had vaginal deliveries only, according to a study of more than 7,600 women in a Danish patient registry.
Cesarean delivery is the most common major surgery performed in the world, and the rate is rapidly increasing, with the global average cesarean rate estimated at 18.6%, and rates as high as 52% in some European countries. However, the impact cesarean deliveries have on surgical complications later in life has not been thoroughly studied. The study authors said this might be the first population study of the association of cesarean delivery with hysterectomy complications.
Of the 388 women (5%) who had a hysterectomy and then a reoperation within 30 days, the risk increased with the number of previous cesarean deliveries. Those who had vaginal-only deliveries had reoperation rates of 4.4%, compared with 6.2% for those who had one cesarean delivery and 6.8% for those who had two or more. That represents increased risks of 31% and 35% for women who had one cesarean delivery and two or more cesarean deliveries, respectively, compared with women who had only vaginal deliveries.
Likewise, surgical complications were 16% more frequent in women who had one previous cesarean delivery and 30% more likely in women with two or more cesarean deliveries. Women who had two or more cesarean deliveries were almost twice as likely (odds ratio, 1.93) to receive a blood transfusion.
“Our results imply that information on long-term associations should be made more readily available to women, clinicians, and policymakers and suggest that decisions on cesarean delivery should take into account not only immediate maternal and neonatal influences, but also women’s health in the long term, including an increased risk of reoperation and complications associated with surgery later in life,” the researchers wrote. “The results support policies and clinical efforts to prevent cesarean deliveries that are not medically indicated.”
The study noted some limitations, including the observational design, which did not allow for elimination of all potential confounding factors.
The researchers reported having no relevant financial disclosures.
Women who have at least one cesarean delivery have a more than 30% risk of a complication requiring reoperation after benign hysterectomy later in life, compared with women who have had vaginal deliveries only, according to a study of more than 7,600 women in a Danish patient registry.
Cesarean delivery is the most common major surgery performed in the world, and the rate is rapidly increasing, with the global average cesarean rate estimated at 18.6%, and rates as high as 52% in some European countries. However, the impact cesarean deliveries have on surgical complications later in life has not been thoroughly studied. The study authors said this might be the first population study of the association of cesarean delivery with hysterectomy complications.
Of the 388 women (5%) who had a hysterectomy and then a reoperation within 30 days, the risk increased with the number of previous cesarean deliveries. Those who had vaginal-only deliveries had reoperation rates of 4.4%, compared with 6.2% for those who had one cesarean delivery and 6.8% for those who had two or more. That represents increased risks of 31% and 35% for women who had one cesarean delivery and two or more cesarean deliveries, respectively, compared with women who had only vaginal deliveries.
Likewise, surgical complications were 16% more frequent in women who had one previous cesarean delivery and 30% more likely in women with two or more cesarean deliveries. Women who had two or more cesarean deliveries were almost twice as likely (odds ratio, 1.93) to receive a blood transfusion.
“Our results imply that information on long-term associations should be made more readily available to women, clinicians, and policymakers and suggest that decisions on cesarean delivery should take into account not only immediate maternal and neonatal influences, but also women’s health in the long term, including an increased risk of reoperation and complications associated with surgery later in life,” the researchers wrote. “The results support policies and clinical efforts to prevent cesarean deliveries that are not medically indicated.”
The study noted some limitations, including the observational design, which did not allow for elimination of all potential confounding factors.
The researchers reported having no relevant financial disclosures.
FROM JAMA SURGERY
Key clinical point:
Major finding: The rate of complications after hysterectomy was 4.4% for women who had vaginal birth only, 6.2% for those who had one cesarean delivery, and 6.8% for those who had two or more cesarean deliveries.
Data source: Danish National Patient Registry–based cohort study of 7,685 women who gave birth from 1993 to 2012.
Disclosures: The researchers reported having no financial disclosures.
FDA approves first spironolactone oral suspension
The Food and Drug Administration has approved CaroSpir, the first oral suspension form of spironolactone, the aldosterone antagonist that was first approved in 1960, according to an announcement from CMP Pharma.
CaroSpir is intended for the treatment of New York Heart Association class III-IV heart failure and reduced ejection fraction, usually in combination with other treatments. CaroSpir is also indicated as an add-on medication for the treatment of hypertension, and for the treatment of edema in cirrhotic patients who have not adequately responded to fluid and sodium restriction.
“CaroSpir provides a stable, ready to use, and consistent liquid treatment option for adult patients. Up until now, these patients have been prescribed a pharmacy-compounded liquid form of spironolactone. The dosing inconsistencies of compounded liquids have long been a persistent challenge for physicians,” Gerald Sakowski, CEO at CMP Pharma, said in the press release.
Find the full press release on the CMP Pharma website.
The Food and Drug Administration has approved CaroSpir, the first oral suspension form of spironolactone, the aldosterone antagonist that was first approved in 1960, according to an announcement from CMP Pharma.
CaroSpir is intended for the treatment of New York Heart Association class III-IV heart failure and reduced ejection fraction, usually in combination with other treatments. CaroSpir is also indicated as an add-on medication for the treatment of hypertension, and for the treatment of edema in cirrhotic patients who have not adequately responded to fluid and sodium restriction.
“CaroSpir provides a stable, ready to use, and consistent liquid treatment option for adult patients. Up until now, these patients have been prescribed a pharmacy-compounded liquid form of spironolactone. The dosing inconsistencies of compounded liquids have long been a persistent challenge for physicians,” Gerald Sakowski, CEO at CMP Pharma, said in the press release.
Find the full press release on the CMP Pharma website.
The Food and Drug Administration has approved CaroSpir, the first oral suspension form of spironolactone, the aldosterone antagonist that was first approved in 1960, according to an announcement from CMP Pharma.
CaroSpir is intended for the treatment of New York Heart Association class III-IV heart failure and reduced ejection fraction, usually in combination with other treatments. CaroSpir is also indicated as an add-on medication for the treatment of hypertension, and for the treatment of edema in cirrhotic patients who have not adequately responded to fluid and sodium restriction.
“CaroSpir provides a stable, ready to use, and consistent liquid treatment option for adult patients. Up until now, these patients have been prescribed a pharmacy-compounded liquid form of spironolactone. The dosing inconsistencies of compounded liquids have long been a persistent challenge for physicians,” Gerald Sakowski, CEO at CMP Pharma, said in the press release.
Find the full press release on the CMP Pharma website.
Inactivated flu vaccine more effective than live version
The inactivated influenza vaccine is more effective than the quadrivalent live attenuated vaccine, according to a study conducted by the Influenza Vaccine Effectiveness Network.
After poor live vaccine performance in young children during the 2013-2014 flu season, the A(H1N1)pdm09 strain was changed. In response to earlier reports that the A(H1N1)pdm09 vaccine strain had poor thermostability, it was updated to A/Bolivia/559/2013 (an A/California/7/2009-like virus) for the 2015-2016 influenza season. Unfortunately, the changes did not increase the vaccine’s immunogenicity. At study sites in Michigan, Pennsylvania, Texas, Washington, and Wisconsin, 6,879 patients aged 6 months or older who presented for acute respiratory illness with a cough of 7 or fewer days were tested for influenza. Of those, 1,309 (19%) tested positive. Vaccination histories were taken from parent interviews and electronic health records.
“Although the quadrivalent live attenuated vaccine remains licensed in the United States, the [Advisory Committee on Immunization Practices] did not recommend this vaccine for the 2016-2017 influenza season,” the investigators wrote.
Partial funding for the research came from the Centers for Disease Control and Prevention and the National Institutes of Health. Dr. Jackson reported receiving a grant from Medimmune.
Read more in the New England Journal of Medicine (2017;377:534-43).
The inactivated influenza vaccine is more effective than the quadrivalent live attenuated vaccine, according to a study conducted by the Influenza Vaccine Effectiveness Network.
After poor live vaccine performance in young children during the 2013-2014 flu season, the A(H1N1)pdm09 strain was changed. In response to earlier reports that the A(H1N1)pdm09 vaccine strain had poor thermostability, it was updated to A/Bolivia/559/2013 (an A/California/7/2009-like virus) for the 2015-2016 influenza season. Unfortunately, the changes did not increase the vaccine’s immunogenicity. At study sites in Michigan, Pennsylvania, Texas, Washington, and Wisconsin, 6,879 patients aged 6 months or older who presented for acute respiratory illness with a cough of 7 or fewer days were tested for influenza. Of those, 1,309 (19%) tested positive. Vaccination histories were taken from parent interviews and electronic health records.
“Although the quadrivalent live attenuated vaccine remains licensed in the United States, the [Advisory Committee on Immunization Practices] did not recommend this vaccine for the 2016-2017 influenza season,” the investigators wrote.
Partial funding for the research came from the Centers for Disease Control and Prevention and the National Institutes of Health. Dr. Jackson reported receiving a grant from Medimmune.
Read more in the New England Journal of Medicine (2017;377:534-43).
The inactivated influenza vaccine is more effective than the quadrivalent live attenuated vaccine, according to a study conducted by the Influenza Vaccine Effectiveness Network.
After poor live vaccine performance in young children during the 2013-2014 flu season, the A(H1N1)pdm09 strain was changed. In response to earlier reports that the A(H1N1)pdm09 vaccine strain had poor thermostability, it was updated to A/Bolivia/559/2013 (an A/California/7/2009-like virus) for the 2015-2016 influenza season. Unfortunately, the changes did not increase the vaccine’s immunogenicity. At study sites in Michigan, Pennsylvania, Texas, Washington, and Wisconsin, 6,879 patients aged 6 months or older who presented for acute respiratory illness with a cough of 7 or fewer days were tested for influenza. Of those, 1,309 (19%) tested positive. Vaccination histories were taken from parent interviews and electronic health records.
“Although the quadrivalent live attenuated vaccine remains licensed in the United States, the [Advisory Committee on Immunization Practices] did not recommend this vaccine for the 2016-2017 influenza season,” the investigators wrote.
Partial funding for the research came from the Centers for Disease Control and Prevention and the National Institutes of Health. Dr. Jackson reported receiving a grant from Medimmune.
Read more in the New England Journal of Medicine (2017;377:534-43).
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Researchers identify ‘congenital NAD deficiency disorders’
Mutations that disrupt de novo synthesis of nicotinamide adenine dinucleotide (NAD) were associated with multiple congenital malformations in humans and mice, and supplementing niacin during gestation prevented these malformations in mice, new research suggests.
The malformations include vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula, renal anomalies, and limb abnormalities (VACTERL), “a nonrandom combination of congenital defects without a known cause,” wrote Hongjun Shi, PhD, of Victor Chang Cardiac Research Institute, New South Wales, Australia, and colleagues (N Engl J Med. 2017;377:544-52).
Numerous genetic and environmental factors can potentially cause NAD deficiency during gestation and the investigators suggested collectively referring to the resulting malformations as “congenital NAD deficiency disorders.”
Congenital defects can occur together in newborns more often than would be expected by chance, but “in many such cases, it has proved difficult to identify a genetic cause,” the investigators noted. Using genomic sequencing, they looked for possible pathogenic gene variants within four unrelated families in which a person was born with multiple congenital malformations. Next, they evaluated the function of the variants by testing in vitro enzyme activity and measuring relevant plasma metabolites. Finally, they used the CRISPR (clustered regularly interspaced short palindromic repeats)–Cas9 system to create mouse models with similar variants.
This approach identified variants in two genes encoding enzymes of the kynurenine pathway: 3-hydroxyanthranilic acid 3,4-dioxygenase (HAAO) and kynureninase (KYNU). Three patients had homozygous variants associated with loss-of-function changes in these proteins. A fourth patient had heterozygous variants in the gene encoding KYNU.
“The mutant enzymes had greatly reduced activity in vitro,” the researchers wrote. Patients had decreased circulating levels of NAD, which tryptophan synthesizes through the kynurenine pathway. Notably, mouse embryos lacking the mouse equivalents of HAAO or KYNU also had congenital defects associated with NAD deficiency. Preventing NAD deficiency during gestation averted these defects in mice.
“The NAD de novo synthesis pathway catabolizes tryptophan,” the researchers added. “Although metabolite levels upstream of the block are elevated, and the metabolites have postnatal functions, we found that it is the deficiency in embryonic NAD, downstream of the block, that is disrupting embryogenesis.”
The study was supported by the Australian and New South Wales governments and foundations. The investigators reported having no other financial disclosures.
Shi et al. report that a deficiency of nicotinamide adenine dinucleotide (NAD) causes congenital malformations, suggesting that interventions to raise NAD levels during fetal and early postnatal development might further reduce the incidence of congenital anomalies.
Regardless of how NAD depletion leads to congenital malformations (whether by compromising the detection of DNA damage by PARP proteins, reducing the supply of nucleotides, or both), dietary supplementation with NAD precursors merits further study. At high doses, niacin can cause flushing and gastrointestinal symptoms, but it has few side effects at lower doses.
Nicotinamide mononucleotide, nicotinamide riboside, and nicotinamide itself are better tolerated than niacin and are generally considered to be safe as dietary supplements, but the doses of NAD precursors required to reduce the risk of congenital malformations in humans are not known. Also unknown is the extent to which raising dietary levels of NAD would limit cognitive impairment in infants with congenital malformations.
Matthew G. Vander Heiden, MD, PhD, is with the Massachusetts Institute of Technology, Cambridge, Mass., and the Dana Farber Cancer Center, Boston. He reported receiving personal fees from Agios Pharmaceuticals and Aeglea Biotherapeutics outside the submitted work. These comments are adapted from an editorial (N Engl J Med. 2007;377:509-11).
Shi et al. report that a deficiency of nicotinamide adenine dinucleotide (NAD) causes congenital malformations, suggesting that interventions to raise NAD levels during fetal and early postnatal development might further reduce the incidence of congenital anomalies.
Regardless of how NAD depletion leads to congenital malformations (whether by compromising the detection of DNA damage by PARP proteins, reducing the supply of nucleotides, or both), dietary supplementation with NAD precursors merits further study. At high doses, niacin can cause flushing and gastrointestinal symptoms, but it has few side effects at lower doses.
Nicotinamide mononucleotide, nicotinamide riboside, and nicotinamide itself are better tolerated than niacin and are generally considered to be safe as dietary supplements, but the doses of NAD precursors required to reduce the risk of congenital malformations in humans are not known. Also unknown is the extent to which raising dietary levels of NAD would limit cognitive impairment in infants with congenital malformations.
Matthew G. Vander Heiden, MD, PhD, is with the Massachusetts Institute of Technology, Cambridge, Mass., and the Dana Farber Cancer Center, Boston. He reported receiving personal fees from Agios Pharmaceuticals and Aeglea Biotherapeutics outside the submitted work. These comments are adapted from an editorial (N Engl J Med. 2007;377:509-11).
Shi et al. report that a deficiency of nicotinamide adenine dinucleotide (NAD) causes congenital malformations, suggesting that interventions to raise NAD levels during fetal and early postnatal development might further reduce the incidence of congenital anomalies.
Regardless of how NAD depletion leads to congenital malformations (whether by compromising the detection of DNA damage by PARP proteins, reducing the supply of nucleotides, or both), dietary supplementation with NAD precursors merits further study. At high doses, niacin can cause flushing and gastrointestinal symptoms, but it has few side effects at lower doses.
Nicotinamide mononucleotide, nicotinamide riboside, and nicotinamide itself are better tolerated than niacin and are generally considered to be safe as dietary supplements, but the doses of NAD precursors required to reduce the risk of congenital malformations in humans are not known. Also unknown is the extent to which raising dietary levels of NAD would limit cognitive impairment in infants with congenital malformations.
Matthew G. Vander Heiden, MD, PhD, is with the Massachusetts Institute of Technology, Cambridge, Mass., and the Dana Farber Cancer Center, Boston. He reported receiving personal fees from Agios Pharmaceuticals and Aeglea Biotherapeutics outside the submitted work. These comments are adapted from an editorial (N Engl J Med. 2007;377:509-11).
Mutations that disrupt de novo synthesis of nicotinamide adenine dinucleotide (NAD) were associated with multiple congenital malformations in humans and mice, and supplementing niacin during gestation prevented these malformations in mice, new research suggests.
The malformations include vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula, renal anomalies, and limb abnormalities (VACTERL), “a nonrandom combination of congenital defects without a known cause,” wrote Hongjun Shi, PhD, of Victor Chang Cardiac Research Institute, New South Wales, Australia, and colleagues (N Engl J Med. 2017;377:544-52).
Numerous genetic and environmental factors can potentially cause NAD deficiency during gestation and the investigators suggested collectively referring to the resulting malformations as “congenital NAD deficiency disorders.”
Congenital defects can occur together in newborns more often than would be expected by chance, but “in many such cases, it has proved difficult to identify a genetic cause,” the investigators noted. Using genomic sequencing, they looked for possible pathogenic gene variants within four unrelated families in which a person was born with multiple congenital malformations. Next, they evaluated the function of the variants by testing in vitro enzyme activity and measuring relevant plasma metabolites. Finally, they used the CRISPR (clustered regularly interspaced short palindromic repeats)–Cas9 system to create mouse models with similar variants.
This approach identified variants in two genes encoding enzymes of the kynurenine pathway: 3-hydroxyanthranilic acid 3,4-dioxygenase (HAAO) and kynureninase (KYNU). Three patients had homozygous variants associated with loss-of-function changes in these proteins. A fourth patient had heterozygous variants in the gene encoding KYNU.
“The mutant enzymes had greatly reduced activity in vitro,” the researchers wrote. Patients had decreased circulating levels of NAD, which tryptophan synthesizes through the kynurenine pathway. Notably, mouse embryos lacking the mouse equivalents of HAAO or KYNU also had congenital defects associated with NAD deficiency. Preventing NAD deficiency during gestation averted these defects in mice.
“The NAD de novo synthesis pathway catabolizes tryptophan,” the researchers added. “Although metabolite levels upstream of the block are elevated, and the metabolites have postnatal functions, we found that it is the deficiency in embryonic NAD, downstream of the block, that is disrupting embryogenesis.”
The study was supported by the Australian and New South Wales governments and foundations. The investigators reported having no other financial disclosures.
Mutations that disrupt de novo synthesis of nicotinamide adenine dinucleotide (NAD) were associated with multiple congenital malformations in humans and mice, and supplementing niacin during gestation prevented these malformations in mice, new research suggests.
The malformations include vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula, renal anomalies, and limb abnormalities (VACTERL), “a nonrandom combination of congenital defects without a known cause,” wrote Hongjun Shi, PhD, of Victor Chang Cardiac Research Institute, New South Wales, Australia, and colleagues (N Engl J Med. 2017;377:544-52).
Numerous genetic and environmental factors can potentially cause NAD deficiency during gestation and the investigators suggested collectively referring to the resulting malformations as “congenital NAD deficiency disorders.”
Congenital defects can occur together in newborns more often than would be expected by chance, but “in many such cases, it has proved difficult to identify a genetic cause,” the investigators noted. Using genomic sequencing, they looked for possible pathogenic gene variants within four unrelated families in which a person was born with multiple congenital malformations. Next, they evaluated the function of the variants by testing in vitro enzyme activity and measuring relevant plasma metabolites. Finally, they used the CRISPR (clustered regularly interspaced short palindromic repeats)–Cas9 system to create mouse models with similar variants.
This approach identified variants in two genes encoding enzymes of the kynurenine pathway: 3-hydroxyanthranilic acid 3,4-dioxygenase (HAAO) and kynureninase (KYNU). Three patients had homozygous variants associated with loss-of-function changes in these proteins. A fourth patient had heterozygous variants in the gene encoding KYNU.
“The mutant enzymes had greatly reduced activity in vitro,” the researchers wrote. Patients had decreased circulating levels of NAD, which tryptophan synthesizes through the kynurenine pathway. Notably, mouse embryos lacking the mouse equivalents of HAAO or KYNU also had congenital defects associated with NAD deficiency. Preventing NAD deficiency during gestation averted these defects in mice.
“The NAD de novo synthesis pathway catabolizes tryptophan,” the researchers added. “Although metabolite levels upstream of the block are elevated, and the metabolites have postnatal functions, we found that it is the deficiency in embryonic NAD, downstream of the block, that is disrupting embryogenesis.”
The study was supported by the Australian and New South Wales governments and foundations. The investigators reported having no other financial disclosures.
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Key clinical point:
Major finding: Major congenital defects affecting unrelated families were associated with variants in genes encoding 3-hydroxyanthranilic acid 3,4-dioxygenase (HAAO) and kynureninase (KYNU).
Data source: Genomic sequencing of four unrelated families in which a person was born with multiple congenital malformations, plus in vitro measurements of enzyme activity and plasma metabolites and studies of mouse models created with the CRISPR–Cas9 system.
Disclosures: The study was supported by the Australian and New South Wales governments and foundations. The investigators reported having no other financial disclosures.
Cosmetic Corner: Dermatologists Weigh in on Men’s Products
To improve patient care and outcomes, leading dermatologists offered their recommendations on men’s products. Consideration must be given to:
- bareMinerals SPF 30 Natural Sunscreen
Bare Escentuals Beauty, Inc
“I recommend this product to my male patients when they are not wearing a hat. It protects the scalp from UV damage without a heavy greasy finish.”—Shari Lipner, MD, PhD, New York, New York
- Ducray Alopexy 5% For Men
Pierre Fabre Laboratories
“This dermatologist-dispensed product for men addresses chronic hair loss as well as thinning hair. It contains an optimal level of minoxidil 5% in an elegant unscented formulation and is designed to spray on smoothly and evenly.”—Jeannette Graf, MD, Great Neck, New York
- Facial Fuel Energizing Scrub
Kiehl’s
“This product is great for oily skin and enlarged pores. The particles in the product allow one to get a deep-clean feeling.”—Gary Goldenberg, MD, New York, New York
- Physical Matte UV Defense SPF 50
SkinCeuticals
“For men I like to keep things simple. I recommend what I use with the single most important thing being daily sun protection. SkinCeuticals Physical Matte UV Defense SPF 50 is my favorite and I use it after I shave. It goes on smoothly and has a natural tint along with a high SPF.”—Jerome Potozkin, MD, Danville, California
- Ultimate Brushless Shave Cream
Kiehl’s
“I recommend this product for men with frequent irritation from shaving. This cream-based product helps to provide a close shave without as much irritation from other gel-based products. A small amount goes a long way!”—Anthony M. Rossi, MD, New York, New York
Cutis invites readers to send us their recommendations. Athlete’s foot treatments and cleansing devices will be featured in upcoming editions of Cosmetic Corner. Please email your recommendation(s) to the Editorial Office.
Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.
To improve patient care and outcomes, leading dermatologists offered their recommendations on men’s products. Consideration must be given to:
- bareMinerals SPF 30 Natural Sunscreen
Bare Escentuals Beauty, Inc
“I recommend this product to my male patients when they are not wearing a hat. It protects the scalp from UV damage without a heavy greasy finish.”—Shari Lipner, MD, PhD, New York, New York
- Ducray Alopexy 5% For Men
Pierre Fabre Laboratories
“This dermatologist-dispensed product for men addresses chronic hair loss as well as thinning hair. It contains an optimal level of minoxidil 5% in an elegant unscented formulation and is designed to spray on smoothly and evenly.”—Jeannette Graf, MD, Great Neck, New York
- Facial Fuel Energizing Scrub
Kiehl’s
“This product is great for oily skin and enlarged pores. The particles in the product allow one to get a deep-clean feeling.”—Gary Goldenberg, MD, New York, New York
- Physical Matte UV Defense SPF 50
SkinCeuticals
“For men I like to keep things simple. I recommend what I use with the single most important thing being daily sun protection. SkinCeuticals Physical Matte UV Defense SPF 50 is my favorite and I use it after I shave. It goes on smoothly and has a natural tint along with a high SPF.”—Jerome Potozkin, MD, Danville, California
- Ultimate Brushless Shave Cream
Kiehl’s
“I recommend this product for men with frequent irritation from shaving. This cream-based product helps to provide a close shave without as much irritation from other gel-based products. A small amount goes a long way!”—Anthony M. Rossi, MD, New York, New York
Cutis invites readers to send us their recommendations. Athlete’s foot treatments and cleansing devices will be featured in upcoming editions of Cosmetic Corner. Please email your recommendation(s) to the Editorial Office.
Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.
To improve patient care and outcomes, leading dermatologists offered their recommendations on men’s products. Consideration must be given to:
- bareMinerals SPF 30 Natural Sunscreen
Bare Escentuals Beauty, Inc
“I recommend this product to my male patients when they are not wearing a hat. It protects the scalp from UV damage without a heavy greasy finish.”—Shari Lipner, MD, PhD, New York, New York
- Ducray Alopexy 5% For Men
Pierre Fabre Laboratories
“This dermatologist-dispensed product for men addresses chronic hair loss as well as thinning hair. It contains an optimal level of minoxidil 5% in an elegant unscented formulation and is designed to spray on smoothly and evenly.”—Jeannette Graf, MD, Great Neck, New York
- Facial Fuel Energizing Scrub
Kiehl’s
“This product is great for oily skin and enlarged pores. The particles in the product allow one to get a deep-clean feeling.”—Gary Goldenberg, MD, New York, New York
- Physical Matte UV Defense SPF 50
SkinCeuticals
“For men I like to keep things simple. I recommend what I use with the single most important thing being daily sun protection. SkinCeuticals Physical Matte UV Defense SPF 50 is my favorite and I use it after I shave. It goes on smoothly and has a natural tint along with a high SPF.”—Jerome Potozkin, MD, Danville, California
- Ultimate Brushless Shave Cream
Kiehl’s
“I recommend this product for men with frequent irritation from shaving. This cream-based product helps to provide a close shave without as much irritation from other gel-based products. A small amount goes a long way!”—Anthony M. Rossi, MD, New York, New York
Cutis invites readers to send us their recommendations. Athlete’s foot treatments and cleansing devices will be featured in upcoming editions of Cosmetic Corner. Please email your recommendation(s) to the Editorial Office.
Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.
Childhood poverty sets stage for adult heart disease
Children from the poorest families show signs of thicker carotid artery walls that may raise their risk for heart attack and stroke as adults, according to data from a longitudinal study of more than 1,000 families in Australia.
“Understanding when associations between SEP [socioeconomic position] and CVD [cardiovascular disease] first appear may help address the increasing social gradients in CVD outcomes and risk factors,” wrote Richard S. Liu, MD, of the Murdoch Children’s Research Institute, Parkville, Australia, and colleagues.
The researchers reviewed data from 1,477 families in Australia. Socioeconomic position of the children’s families was measured biennially at age 0-1 year and onward, and the researchers used imaging to measure the right carotid arteries of children between age 11 and 12 years. Overall, children in the lowest socioeconomic quartile at age 11-12 years were 46% more likely than those in the highest quartile to have thicker carotid arteries (defined as greater than the 75th percentile).
“In univariable analyses, each quartile increment higher of family SEP was associated with a 3.7-micrometer thicker carotid intima-media thickness [IMT],” and the association remained significant in a multivariate analysis controlling for cardiovascular risk factors including secondhand smoke, body weight, and blood pressure, the researchers wrote.
The socioeconomic status of the family had a greater impact than that of the neighborhood, they noted.
In addition, low socioeconomic status of a child’s family at age 2-3 years was associated with thickness in carotid artery measurements at age 11-12 years.
The study findings were limited by several factors, including a lack of data on the clinical consequences of increased carotid thickness in children, as well as the need for investigation of other signs of subclinical atherosclerosis, the researchers said. However, “consistent evidence showed an association between SEP from early life and midchildhood carotid IMT,” and additional research is needed to explore the impact of household factors on childhood health, they emphasized.
The findings were published online Aug. 9 in the Journal of the American Heart Association (J Am Heart Assoc. 2017;6:e0059255).
The study was funded by the National Health and Medical Research Council of Australia and several research institutions. The researchers had no financial conflicts to disclose.
Children from the poorest families show signs of thicker carotid artery walls that may raise their risk for heart attack and stroke as adults, according to data from a longitudinal study of more than 1,000 families in Australia.
“Understanding when associations between SEP [socioeconomic position] and CVD [cardiovascular disease] first appear may help address the increasing social gradients in CVD outcomes and risk factors,” wrote Richard S. Liu, MD, of the Murdoch Children’s Research Institute, Parkville, Australia, and colleagues.
The researchers reviewed data from 1,477 families in Australia. Socioeconomic position of the children’s families was measured biennially at age 0-1 year and onward, and the researchers used imaging to measure the right carotid arteries of children between age 11 and 12 years. Overall, children in the lowest socioeconomic quartile at age 11-12 years were 46% more likely than those in the highest quartile to have thicker carotid arteries (defined as greater than the 75th percentile).
“In univariable analyses, each quartile increment higher of family SEP was associated with a 3.7-micrometer thicker carotid intima-media thickness [IMT],” and the association remained significant in a multivariate analysis controlling for cardiovascular risk factors including secondhand smoke, body weight, and blood pressure, the researchers wrote.
The socioeconomic status of the family had a greater impact than that of the neighborhood, they noted.
In addition, low socioeconomic status of a child’s family at age 2-3 years was associated with thickness in carotid artery measurements at age 11-12 years.
The study findings were limited by several factors, including a lack of data on the clinical consequences of increased carotid thickness in children, as well as the need for investigation of other signs of subclinical atherosclerosis, the researchers said. However, “consistent evidence showed an association between SEP from early life and midchildhood carotid IMT,” and additional research is needed to explore the impact of household factors on childhood health, they emphasized.
The findings were published online Aug. 9 in the Journal of the American Heart Association (J Am Heart Assoc. 2017;6:e0059255).
The study was funded by the National Health and Medical Research Council of Australia and several research institutions. The researchers had no financial conflicts to disclose.
Children from the poorest families show signs of thicker carotid artery walls that may raise their risk for heart attack and stroke as adults, according to data from a longitudinal study of more than 1,000 families in Australia.
“Understanding when associations between SEP [socioeconomic position] and CVD [cardiovascular disease] first appear may help address the increasing social gradients in CVD outcomes and risk factors,” wrote Richard S. Liu, MD, of the Murdoch Children’s Research Institute, Parkville, Australia, and colleagues.
The researchers reviewed data from 1,477 families in Australia. Socioeconomic position of the children’s families was measured biennially at age 0-1 year and onward, and the researchers used imaging to measure the right carotid arteries of children between age 11 and 12 years. Overall, children in the lowest socioeconomic quartile at age 11-12 years were 46% more likely than those in the highest quartile to have thicker carotid arteries (defined as greater than the 75th percentile).
“In univariable analyses, each quartile increment higher of family SEP was associated with a 3.7-micrometer thicker carotid intima-media thickness [IMT],” and the association remained significant in a multivariate analysis controlling for cardiovascular risk factors including secondhand smoke, body weight, and blood pressure, the researchers wrote.
The socioeconomic status of the family had a greater impact than that of the neighborhood, they noted.
In addition, low socioeconomic status of a child’s family at age 2-3 years was associated with thickness in carotid artery measurements at age 11-12 years.
The study findings were limited by several factors, including a lack of data on the clinical consequences of increased carotid thickness in children, as well as the need for investigation of other signs of subclinical atherosclerosis, the researchers said. However, “consistent evidence showed an association between SEP from early life and midchildhood carotid IMT,” and additional research is needed to explore the impact of household factors on childhood health, they emphasized.
The findings were published online Aug. 9 in the Journal of the American Heart Association (J Am Heart Assoc. 2017;6:e0059255).
The study was funded by the National Health and Medical Research Council of Australia and several research institutions. The researchers had no financial conflicts to disclose.
FROM THE JOURNAL OF THE AMERICAN HEART ASSOCIATION
Key clinical point: Low socioeconomic status of families was significantly linked with thicker carotid arteries in children at age 11-12 years, which could increase the risk of stroke in adulthood.
Major finding: Children in the lowest socioeconomic group at age 11-12 years were 46% more likely to have carotid intima-media thickness at a level above the 75th percentile.
Data source: A longitudinal study of children from 1,477 families in Australia.
Disclosures: The study was funded by the National Health and Medical Research Council of Australia and several research institutions. The researchers had no financial conflicts to disclose.
Clues to rosacea in patients of skin of color
NEW YORK – A middle-aged patient with Fitzpatrick type V skin comes to the office with a 10-year history of “breakouts” on her face. When asked about topical treatments, she reports that “everything burns or stings,” and says she just has very sensitive skin. What could this be?
Rosacea may often be missed in skin of color, said Dr. Alexis, speaking at the summer meeting of the American Academy of Dermatology. “It’s reportedly rare in darker skin types, especially in blacks,” and as a result, dermatologists and patients alike have a low index of suspicion for the diagnosis, he noted.
Also, rosacea looks different on darker skin than it does on lighter skin, which is featured in much of the dermatology teaching material. “In richly pigmented [Fitzpatrick] type VI skin, the erythema of rosacea can be masked,” said Dr. Alexis, chairman of the department of dermatology at Mount Sinai St. Luke’s and at Mount Sinai West, both in New York.
Dermatologists, in this case, may have to do some detective work: looking at the distribution of the lesions, thinking about trigger factors from the patient history, and noting the lack of comedones – although the patient has “pimples.” Patient complaints that they are sensitive to almost all topical products and experience stinging with “everything” is another very good clue that the patient may have rosacea.
Keep rosacea on the differential for this picture, advised Dr. Alexis. In skin of color, “rosacea may not be as rare as previously thought – less common, maybe – but not rare.”
Dr. Alexis reported financial relationships with multiple pharmaceutical companies.
[email protected]
On Twitter @karioakes
NEW YORK – A middle-aged patient with Fitzpatrick type V skin comes to the office with a 10-year history of “breakouts” on her face. When asked about topical treatments, she reports that “everything burns or stings,” and says she just has very sensitive skin. What could this be?
Rosacea may often be missed in skin of color, said Dr. Alexis, speaking at the summer meeting of the American Academy of Dermatology. “It’s reportedly rare in darker skin types, especially in blacks,” and as a result, dermatologists and patients alike have a low index of suspicion for the diagnosis, he noted.
Also, rosacea looks different on darker skin than it does on lighter skin, which is featured in much of the dermatology teaching material. “In richly pigmented [Fitzpatrick] type VI skin, the erythema of rosacea can be masked,” said Dr. Alexis, chairman of the department of dermatology at Mount Sinai St. Luke’s and at Mount Sinai West, both in New York.
Dermatologists, in this case, may have to do some detective work: looking at the distribution of the lesions, thinking about trigger factors from the patient history, and noting the lack of comedones – although the patient has “pimples.” Patient complaints that they are sensitive to almost all topical products and experience stinging with “everything” is another very good clue that the patient may have rosacea.
Keep rosacea on the differential for this picture, advised Dr. Alexis. In skin of color, “rosacea may not be as rare as previously thought – less common, maybe – but not rare.”
Dr. Alexis reported financial relationships with multiple pharmaceutical companies.
[email protected]
On Twitter @karioakes
NEW YORK – A middle-aged patient with Fitzpatrick type V skin comes to the office with a 10-year history of “breakouts” on her face. When asked about topical treatments, she reports that “everything burns or stings,” and says she just has very sensitive skin. What could this be?
Rosacea may often be missed in skin of color, said Dr. Alexis, speaking at the summer meeting of the American Academy of Dermatology. “It’s reportedly rare in darker skin types, especially in blacks,” and as a result, dermatologists and patients alike have a low index of suspicion for the diagnosis, he noted.
Also, rosacea looks different on darker skin than it does on lighter skin, which is featured in much of the dermatology teaching material. “In richly pigmented [Fitzpatrick] type VI skin, the erythema of rosacea can be masked,” said Dr. Alexis, chairman of the department of dermatology at Mount Sinai St. Luke’s and at Mount Sinai West, both in New York.
Dermatologists, in this case, may have to do some detective work: looking at the distribution of the lesions, thinking about trigger factors from the patient history, and noting the lack of comedones – although the patient has “pimples.” Patient complaints that they are sensitive to almost all topical products and experience stinging with “everything” is another very good clue that the patient may have rosacea.
Keep rosacea on the differential for this picture, advised Dr. Alexis. In skin of color, “rosacea may not be as rare as previously thought – less common, maybe – but not rare.”
Dr. Alexis reported financial relationships with multiple pharmaceutical companies.
[email protected]
On Twitter @karioakes
EXPERT ANALYSIS FROM THE 2017 AAD SUMMER MEETING
HPV vaccination rose after ACA implementation
Human papillomavirus vaccination in girls and women has increased significantly since the implementation of the Affordable Care Act (ACA), according an analysis of federal survey data.
Overall, girls and women were 3.3 times more likely to receive the vaccine (95% confidence interval, 2.0, 5.5; P less than .0001) in the post–ACA implementation period, compared with the pre-ACA period. They were 5.8 times more likely to receive all three doses of the vaccine (95% CI, 2.5-13.6; P = .0001) post ACA, compared with one dose during that period, according to Rosemary Corriero of the University of Georgia, Athens, who is also a fellow at the Centers for Disease Control and Prevention, and her coauthors (J Pediatr Adolesc Gynecol. 2017 Jul 26. doi: 10.1016/j.jpag.2017.07.002).
The cross-sectional analysis included four waves of data from 2007-2008, 2009-2010, 2011-2012, and 2013-2014 – two waves before the ACA and two waves after. The data comes from the National Health and Nutrition Examination Survey (NHANES) questionnaire. In the pre-ACA surveys, 2,452 teenage girls and women were included, compared with 2,147 in the post-ACA years. The majority of participants were white, and analysis was limited to those aged 9-33 years.
The increase in vaccination could be due to the ACA’s provision requiring coverage of preventive health services without patient cost sharing in most health plans, but the investigators couldn’t say for sure.
Vaccination uptake was significantly higher for those with insurance coverage in both pre- and post-ACA groups (P = .0007 and P = .01, respectively).
Despite these increases, vaccination rates are still low. There has been progress, but “physicians and public health professionals could assist in the acceleration of HPV vaccination uptake by increasing communication of HPV vaccination importance and by utilizing campaigns and materials that are readily available,” the investigators wrote.
The study was limited by a lack of data for teenage boys and men before implementation of the ACA and by the overlap in pre- and post-ACA data in the 2009-2010 wave because of the timing of the provision. Additionally, the data was self-reported.
The investigators reported having no relevant financial disclosures.
Human papillomavirus vaccination in girls and women has increased significantly since the implementation of the Affordable Care Act (ACA), according an analysis of federal survey data.
Overall, girls and women were 3.3 times more likely to receive the vaccine (95% confidence interval, 2.0, 5.5; P less than .0001) in the post–ACA implementation period, compared with the pre-ACA period. They were 5.8 times more likely to receive all three doses of the vaccine (95% CI, 2.5-13.6; P = .0001) post ACA, compared with one dose during that period, according to Rosemary Corriero of the University of Georgia, Athens, who is also a fellow at the Centers for Disease Control and Prevention, and her coauthors (J Pediatr Adolesc Gynecol. 2017 Jul 26. doi: 10.1016/j.jpag.2017.07.002).
The cross-sectional analysis included four waves of data from 2007-2008, 2009-2010, 2011-2012, and 2013-2014 – two waves before the ACA and two waves after. The data comes from the National Health and Nutrition Examination Survey (NHANES) questionnaire. In the pre-ACA surveys, 2,452 teenage girls and women were included, compared with 2,147 in the post-ACA years. The majority of participants were white, and analysis was limited to those aged 9-33 years.
The increase in vaccination could be due to the ACA’s provision requiring coverage of preventive health services without patient cost sharing in most health plans, but the investigators couldn’t say for sure.
Vaccination uptake was significantly higher for those with insurance coverage in both pre- and post-ACA groups (P = .0007 and P = .01, respectively).
Despite these increases, vaccination rates are still low. There has been progress, but “physicians and public health professionals could assist in the acceleration of HPV vaccination uptake by increasing communication of HPV vaccination importance and by utilizing campaigns and materials that are readily available,” the investigators wrote.
The study was limited by a lack of data for teenage boys and men before implementation of the ACA and by the overlap in pre- and post-ACA data in the 2009-2010 wave because of the timing of the provision. Additionally, the data was self-reported.
The investigators reported having no relevant financial disclosures.
Human papillomavirus vaccination in girls and women has increased significantly since the implementation of the Affordable Care Act (ACA), according an analysis of federal survey data.
Overall, girls and women were 3.3 times more likely to receive the vaccine (95% confidence interval, 2.0, 5.5; P less than .0001) in the post–ACA implementation period, compared with the pre-ACA period. They were 5.8 times more likely to receive all three doses of the vaccine (95% CI, 2.5-13.6; P = .0001) post ACA, compared with one dose during that period, according to Rosemary Corriero of the University of Georgia, Athens, who is also a fellow at the Centers for Disease Control and Prevention, and her coauthors (J Pediatr Adolesc Gynecol. 2017 Jul 26. doi: 10.1016/j.jpag.2017.07.002).
The cross-sectional analysis included four waves of data from 2007-2008, 2009-2010, 2011-2012, and 2013-2014 – two waves before the ACA and two waves after. The data comes from the National Health and Nutrition Examination Survey (NHANES) questionnaire. In the pre-ACA surveys, 2,452 teenage girls and women were included, compared with 2,147 in the post-ACA years. The majority of participants were white, and analysis was limited to those aged 9-33 years.
The increase in vaccination could be due to the ACA’s provision requiring coverage of preventive health services without patient cost sharing in most health plans, but the investigators couldn’t say for sure.
Vaccination uptake was significantly higher for those with insurance coverage in both pre- and post-ACA groups (P = .0007 and P = .01, respectively).
Despite these increases, vaccination rates are still low. There has been progress, but “physicians and public health professionals could assist in the acceleration of HPV vaccination uptake by increasing communication of HPV vaccination importance and by utilizing campaigns and materials that are readily available,” the investigators wrote.
The study was limited by a lack of data for teenage boys and men before implementation of the ACA and by the overlap in pre- and post-ACA data in the 2009-2010 wave because of the timing of the provision. Additionally, the data was self-reported.
The investigators reported having no relevant financial disclosures.
FROM THE JOURNAL OF PEDIATRIC & ADOLESCENT GYNECOLOGY
Key clinical point:
Major finding: Girls and women were 3.3 times more likely to receive the HPV vaccine in the period after the ACA was implemented (95% confidence interval, 2.0-5.5; P less than .0001).
Data source: A cross-sectional analysis of the NHANES questionnaire that included responses from more than 4,500 girls and women aged 9-33 years.
Disclosures: The investigators reported having no relevant financial disclosures.
Prenatal ART regimen with lowest risk is TDF-FTC-EFV
The antiretroviral therapy (ART) regimen associated with the least risk of adverse birth outcomes among pregnant women with HIV, relative to other regimens, is tenofovir disoproxil fumarate (TDF), emtricitabine (FTC), and efavirenz (EFV), according to a new study.
“Our results provide reassurance for the more than 90% of HIV-infected women who live in countries that follow WHO recommendations to use TDF-FTC-EFV,” wrote Rebecca Zash, MD, of Beth Israel Deaconess Medical Center in Boston and her associates in JAMA Pediatrics.
Using data collected from August 2014 through August 2016, the researchers compared outcomes among 47,027 births by women from Botswana, average age 26 years, who reached at least 24 weeks’ gestation. The study’s data came from eight government hospitals throughout Botswana, where approximately 45% of births had occurred nationwide.
The 11,932 infants exposed to HIV, representing about a quarter of all infants in the study, had a higher risk of adverse birth outcomes: 39.6% of HIV-exposed infants had adverse outcomes, compared with 28.9% of unexposed infants.
Nearly half (48.4%) of the HIV-exposed infants had also been exposed to ART from conception. Among these 5,780 infants, those exposed to the ART regimen comprising tenofovir disoproxil fumarate (TDF), emtricitabine (FTC), and efavirenz (EFV) had the lowest rate of adverse birth outcomes. The following percentages of infants exposed to different ART regimens had adverse outcomes:
- 36.4% of infants exposed to TDF-FTC-EFV.
- 41.7% of infants exposed to TDF-FTC and nevirapine (NVP).
- 44.9% of infants exposed to zidovudine (ZDV), lamivudine (3TC), and lopinavir-ritonavir (LPV-R).
- 47.4% of infants exposed to ZDV-3TC-NVP.
- 48.5% of infants exposed to TDF-FTC-LPV-R.
The risk of adverse birth outcomes, compared with exposure to TDF-FTC-EFV, was 15% higher for TDF-FTC-NVP, 21% higher for ZDV-3TC-LPV-R, 30% higher for ZDV-3TC-NVP, and 31% higher for TDF-FTC-LPV-R after researchers adjusted for age and potential sociodemographic confounders.
The risk of severe adverse outcomes for ART exposure from conception was as follows:
- 12.3% for exposure to TDF-FTC-EFV.
- 17.9% for exposure to TDF-FTC-NVP.
- 19.5% for TDF-FTC–LPV-R.
- 20.7% for ZDV-3TC-NVP.
- 23.4% for ZDV-3TC–LPV-R.
The risk for giving birth to an infant small for gestational age was lowest for TDF-FTC-EFV, compared with the other regimens.
“Differences between TDF-FTC-EFV and other ART regimens were greater for small for gestational age than for preterm birth,” suggesting a “drug-specific mechanism at the placental level because the health of the placenta is directly related to fetal growth,” the researchers wrote. “An ART effect at the level of the placenta may also explain why women receiving ART before conception have more adverse outcomes than [do] those who start ART after conception because endothelial dysfunction during placentation would be expected to have a more detrimental effect on the pregnancy,” they added.
The ZDV-3TC-NVP regimen was linked to greater risk for stillbirth, very preterm birth, and neonatal death; the ZDV-3TC-LPV-R regimen was linked to a greater risk of preterm and very preterm birth, as well as neonatal death.
“Our study findings may be difficult to integrate into settings with ART regimen choices beyond those available in Botswana,” the authors wrote. “Whether the magnitude of the differences we found in Botswana will be similar in higher-resource settings is unclear.”
The research was funded by the National Institutes of Health. The authors reported no conflicts of interest.
The antiretroviral therapy (ART) regimen associated with the least risk of adverse birth outcomes among pregnant women with HIV, relative to other regimens, is tenofovir disoproxil fumarate (TDF), emtricitabine (FTC), and efavirenz (EFV), according to a new study.
“Our results provide reassurance for the more than 90% of HIV-infected women who live in countries that follow WHO recommendations to use TDF-FTC-EFV,” wrote Rebecca Zash, MD, of Beth Israel Deaconess Medical Center in Boston and her associates in JAMA Pediatrics.
Using data collected from August 2014 through August 2016, the researchers compared outcomes among 47,027 births by women from Botswana, average age 26 years, who reached at least 24 weeks’ gestation. The study’s data came from eight government hospitals throughout Botswana, where approximately 45% of births had occurred nationwide.
The 11,932 infants exposed to HIV, representing about a quarter of all infants in the study, had a higher risk of adverse birth outcomes: 39.6% of HIV-exposed infants had adverse outcomes, compared with 28.9% of unexposed infants.
Nearly half (48.4%) of the HIV-exposed infants had also been exposed to ART from conception. Among these 5,780 infants, those exposed to the ART regimen comprising tenofovir disoproxil fumarate (TDF), emtricitabine (FTC), and efavirenz (EFV) had the lowest rate of adverse birth outcomes. The following percentages of infants exposed to different ART regimens had adverse outcomes:
- 36.4% of infants exposed to TDF-FTC-EFV.
- 41.7% of infants exposed to TDF-FTC and nevirapine (NVP).
- 44.9% of infants exposed to zidovudine (ZDV), lamivudine (3TC), and lopinavir-ritonavir (LPV-R).
- 47.4% of infants exposed to ZDV-3TC-NVP.
- 48.5% of infants exposed to TDF-FTC-LPV-R.
The risk of adverse birth outcomes, compared with exposure to TDF-FTC-EFV, was 15% higher for TDF-FTC-NVP, 21% higher for ZDV-3TC-LPV-R, 30% higher for ZDV-3TC-NVP, and 31% higher for TDF-FTC-LPV-R after researchers adjusted for age and potential sociodemographic confounders.
The risk of severe adverse outcomes for ART exposure from conception was as follows:
- 12.3% for exposure to TDF-FTC-EFV.
- 17.9% for exposure to TDF-FTC-NVP.
- 19.5% for TDF-FTC–LPV-R.
- 20.7% for ZDV-3TC-NVP.
- 23.4% for ZDV-3TC–LPV-R.
The risk for giving birth to an infant small for gestational age was lowest for TDF-FTC-EFV, compared with the other regimens.
“Differences between TDF-FTC-EFV and other ART regimens were greater for small for gestational age than for preterm birth,” suggesting a “drug-specific mechanism at the placental level because the health of the placenta is directly related to fetal growth,” the researchers wrote. “An ART effect at the level of the placenta may also explain why women receiving ART before conception have more adverse outcomes than [do] those who start ART after conception because endothelial dysfunction during placentation would be expected to have a more detrimental effect on the pregnancy,” they added.
The ZDV-3TC-NVP regimen was linked to greater risk for stillbirth, very preterm birth, and neonatal death; the ZDV-3TC-LPV-R regimen was linked to a greater risk of preterm and very preterm birth, as well as neonatal death.
“Our study findings may be difficult to integrate into settings with ART regimen choices beyond those available in Botswana,” the authors wrote. “Whether the magnitude of the differences we found in Botswana will be similar in higher-resource settings is unclear.”
The research was funded by the National Institutes of Health. The authors reported no conflicts of interest.
The antiretroviral therapy (ART) regimen associated with the least risk of adverse birth outcomes among pregnant women with HIV, relative to other regimens, is tenofovir disoproxil fumarate (TDF), emtricitabine (FTC), and efavirenz (EFV), according to a new study.
“Our results provide reassurance for the more than 90% of HIV-infected women who live in countries that follow WHO recommendations to use TDF-FTC-EFV,” wrote Rebecca Zash, MD, of Beth Israel Deaconess Medical Center in Boston and her associates in JAMA Pediatrics.
Using data collected from August 2014 through August 2016, the researchers compared outcomes among 47,027 births by women from Botswana, average age 26 years, who reached at least 24 weeks’ gestation. The study’s data came from eight government hospitals throughout Botswana, where approximately 45% of births had occurred nationwide.
The 11,932 infants exposed to HIV, representing about a quarter of all infants in the study, had a higher risk of adverse birth outcomes: 39.6% of HIV-exposed infants had adverse outcomes, compared with 28.9% of unexposed infants.
Nearly half (48.4%) of the HIV-exposed infants had also been exposed to ART from conception. Among these 5,780 infants, those exposed to the ART regimen comprising tenofovir disoproxil fumarate (TDF), emtricitabine (FTC), and efavirenz (EFV) had the lowest rate of adverse birth outcomes. The following percentages of infants exposed to different ART regimens had adverse outcomes:
- 36.4% of infants exposed to TDF-FTC-EFV.
- 41.7% of infants exposed to TDF-FTC and nevirapine (NVP).
- 44.9% of infants exposed to zidovudine (ZDV), lamivudine (3TC), and lopinavir-ritonavir (LPV-R).
- 47.4% of infants exposed to ZDV-3TC-NVP.
- 48.5% of infants exposed to TDF-FTC-LPV-R.
The risk of adverse birth outcomes, compared with exposure to TDF-FTC-EFV, was 15% higher for TDF-FTC-NVP, 21% higher for ZDV-3TC-LPV-R, 30% higher for ZDV-3TC-NVP, and 31% higher for TDF-FTC-LPV-R after researchers adjusted for age and potential sociodemographic confounders.
The risk of severe adverse outcomes for ART exposure from conception was as follows:
- 12.3% for exposure to TDF-FTC-EFV.
- 17.9% for exposure to TDF-FTC-NVP.
- 19.5% for TDF-FTC–LPV-R.
- 20.7% for ZDV-3TC-NVP.
- 23.4% for ZDV-3TC–LPV-R.
The risk for giving birth to an infant small for gestational age was lowest for TDF-FTC-EFV, compared with the other regimens.
“Differences between TDF-FTC-EFV and other ART regimens were greater for small for gestational age than for preterm birth,” suggesting a “drug-specific mechanism at the placental level because the health of the placenta is directly related to fetal growth,” the researchers wrote. “An ART effect at the level of the placenta may also explain why women receiving ART before conception have more adverse outcomes than [do] those who start ART after conception because endothelial dysfunction during placentation would be expected to have a more detrimental effect on the pregnancy,” they added.
The ZDV-3TC-NVP regimen was linked to greater risk for stillbirth, very preterm birth, and neonatal death; the ZDV-3TC-LPV-R regimen was linked to a greater risk of preterm and very preterm birth, as well as neonatal death.
“Our study findings may be difficult to integrate into settings with ART regimen choices beyond those available in Botswana,” the authors wrote. “Whether the magnitude of the differences we found in Botswana will be similar in higher-resource settings is unclear.”
The research was funded by the National Institutes of Health. The authors reported no conflicts of interest.
FROM JAMA PEDIATRICS
Key clinical point: Different antiretroviral regimens pose different adverse birth outcome risks for pregnant women with HIV.
Major finding: The ART regimen with the lowest level of risk was tenofovir, emtricitabine, and efavirenz, with a 36.5% risk for adverse outcomes and 12.3% risk for serious adverse outcomes.
Data source: The findings are based on an observational study of 47,027 births to women at eight government hospitals in Botswana from 2014 to 2016.
Disclosures: The research was funded by the National Institutes of Health. The authors reported no conflicts of interest.
Improving children’s sleep may reduce internalizing problems long term
SAN FRANCISCO – , new research showed.
“Interventions addressing externalizing difficulties may lead to improvements in sleep, but addressing internalizing difficulties are unlikely to lead to benefits for children’s sleep,” concluded Jon Quach, PhD, of the University of Melbourne and Murdoch Children’s Research Institute, Victoria, Australia, and his colleagues.
Although they also conclude that “addressing sleep problems at earlier time points may reduce both internalizing and externalizing difficulties,” the researchers said the data are inconsistent, only weakly suggesting that sleep influences later externalizing problems at only two different age points, Dr. Quach said when presenting the findings at the Pediatric Academic Societies meeting.
Data collection every 2 years included parent-reported sleep problems and child behavior. Behavior assessment came from the parent-reported Strengths and Difficulties Questionnaire for externalizing and internalizing difficulties. Parents reported severity of sleep difficulties and presence of specific problems at least 4 nights a week: difficulty falling asleep, night waking, sleep restlessness, and not wanting to sleep alone.
The researchers investigated the direction of influence – potential but unproven causation – between sleep problems and internalizing and externalizing problems. The analysis also assessed the extent of the associations. The first pair of analyses examined the relationship between sleeping and either externalizing or internalizing problems, independently assessed.
The findings revealed that sleeping problems were primarily associated with later internalizing difficulties, strongly suggesting that sleeping issues may cause or contribute to internalizing issues 2 years later.
With externalizing problems, however, the effect of poor sleep was inconsistent: Only at one point did it appear that sleeping difficulties contributed to externalizing difficulties. Instead, externalizing problems appeared to contribute to sleeping difficulties at three out of four time points. (The exception was that externalizing problems at ages 8-9 years did not appear to affect sleep at ages 10-11 years.) Though inconsistent, the results suggest that externalizing problems likely affect difficulty sleeping much more so than the other way around.
Then the researchers assessed the interacting associations between all three factors together. At all ages, poor sleep appeared to lead to internalizing difficulties 2 years later. Only once – at ages 6-7 years – did internalizing problems appear to influence sleep 2 years later.
The relationship between sleeping problems and externalizing problems was more complex and less consistent. Externalizing problems often, but not always, were positively associated with sleeping problems 2 years later. And only at ages 4-5 years did difficulty sleeping appear to lead to externalizing problems at ages 6-7 years.
In addition, independent of any interaction with sleeping problems, externalizing difficulties appeared to lead to internalizing problems at all time points.
Although this type of analysis can strongly suggest a direction of causality, Dr. Quach noted, the associations remain subject to the limitations of any observational data, where clearly determining causation or its direction is not possible.
The Australian Research Council and the National Health Medical Research Council in Australia funded the research. The authors did not report any conflicts of interest.
SAN FRANCISCO – , new research showed.
“Interventions addressing externalizing difficulties may lead to improvements in sleep, but addressing internalizing difficulties are unlikely to lead to benefits for children’s sleep,” concluded Jon Quach, PhD, of the University of Melbourne and Murdoch Children’s Research Institute, Victoria, Australia, and his colleagues.
Although they also conclude that “addressing sleep problems at earlier time points may reduce both internalizing and externalizing difficulties,” the researchers said the data are inconsistent, only weakly suggesting that sleep influences later externalizing problems at only two different age points, Dr. Quach said when presenting the findings at the Pediatric Academic Societies meeting.
Data collection every 2 years included parent-reported sleep problems and child behavior. Behavior assessment came from the parent-reported Strengths and Difficulties Questionnaire for externalizing and internalizing difficulties. Parents reported severity of sleep difficulties and presence of specific problems at least 4 nights a week: difficulty falling asleep, night waking, sleep restlessness, and not wanting to sleep alone.
The researchers investigated the direction of influence – potential but unproven causation – between sleep problems and internalizing and externalizing problems. The analysis also assessed the extent of the associations. The first pair of analyses examined the relationship between sleeping and either externalizing or internalizing problems, independently assessed.
The findings revealed that sleeping problems were primarily associated with later internalizing difficulties, strongly suggesting that sleeping issues may cause or contribute to internalizing issues 2 years later.
With externalizing problems, however, the effect of poor sleep was inconsistent: Only at one point did it appear that sleeping difficulties contributed to externalizing difficulties. Instead, externalizing problems appeared to contribute to sleeping difficulties at three out of four time points. (The exception was that externalizing problems at ages 8-9 years did not appear to affect sleep at ages 10-11 years.) Though inconsistent, the results suggest that externalizing problems likely affect difficulty sleeping much more so than the other way around.
Then the researchers assessed the interacting associations between all three factors together. At all ages, poor sleep appeared to lead to internalizing difficulties 2 years later. Only once – at ages 6-7 years – did internalizing problems appear to influence sleep 2 years later.
The relationship between sleeping problems and externalizing problems was more complex and less consistent. Externalizing problems often, but not always, were positively associated with sleeping problems 2 years later. And only at ages 4-5 years did difficulty sleeping appear to lead to externalizing problems at ages 6-7 years.
In addition, independent of any interaction with sleeping problems, externalizing difficulties appeared to lead to internalizing problems at all time points.
Although this type of analysis can strongly suggest a direction of causality, Dr. Quach noted, the associations remain subject to the limitations of any observational data, where clearly determining causation or its direction is not possible.
The Australian Research Council and the National Health Medical Research Council in Australia funded the research. The authors did not report any conflicts of interest.
SAN FRANCISCO – , new research showed.
“Interventions addressing externalizing difficulties may lead to improvements in sleep, but addressing internalizing difficulties are unlikely to lead to benefits for children’s sleep,” concluded Jon Quach, PhD, of the University of Melbourne and Murdoch Children’s Research Institute, Victoria, Australia, and his colleagues.
Although they also conclude that “addressing sleep problems at earlier time points may reduce both internalizing and externalizing difficulties,” the researchers said the data are inconsistent, only weakly suggesting that sleep influences later externalizing problems at only two different age points, Dr. Quach said when presenting the findings at the Pediatric Academic Societies meeting.
Data collection every 2 years included parent-reported sleep problems and child behavior. Behavior assessment came from the parent-reported Strengths and Difficulties Questionnaire for externalizing and internalizing difficulties. Parents reported severity of sleep difficulties and presence of specific problems at least 4 nights a week: difficulty falling asleep, night waking, sleep restlessness, and not wanting to sleep alone.
The researchers investigated the direction of influence – potential but unproven causation – between sleep problems and internalizing and externalizing problems. The analysis also assessed the extent of the associations. The first pair of analyses examined the relationship between sleeping and either externalizing or internalizing problems, independently assessed.
The findings revealed that sleeping problems were primarily associated with later internalizing difficulties, strongly suggesting that sleeping issues may cause or contribute to internalizing issues 2 years later.
With externalizing problems, however, the effect of poor sleep was inconsistent: Only at one point did it appear that sleeping difficulties contributed to externalizing difficulties. Instead, externalizing problems appeared to contribute to sleeping difficulties at three out of four time points. (The exception was that externalizing problems at ages 8-9 years did not appear to affect sleep at ages 10-11 years.) Though inconsistent, the results suggest that externalizing problems likely affect difficulty sleeping much more so than the other way around.
Then the researchers assessed the interacting associations between all three factors together. At all ages, poor sleep appeared to lead to internalizing difficulties 2 years later. Only once – at ages 6-7 years – did internalizing problems appear to influence sleep 2 years later.
The relationship between sleeping problems and externalizing problems was more complex and less consistent. Externalizing problems often, but not always, were positively associated with sleeping problems 2 years later. And only at ages 4-5 years did difficulty sleeping appear to lead to externalizing problems at ages 6-7 years.
In addition, independent of any interaction with sleeping problems, externalizing difficulties appeared to lead to internalizing problems at all time points.
Although this type of analysis can strongly suggest a direction of causality, Dr. Quach noted, the associations remain subject to the limitations of any observational data, where clearly determining causation or its direction is not possible.
The Australian Research Council and the National Health Medical Research Council in Australia funded the research. The authors did not report any conflicts of interest.
AT PAS 17
Key clinical point: Improving children’s sleep may reduce internalizing problems 2 years later.
Major finding: Externalizing problems were associated with sleep problems later on, and sleeping difficulties were linked to later internalizing problems.
Data source: The findings are based on analysis of four longitudinal, biennial questionnaires from parents of 4,983 Australian children aged 4-5 years, starting in 2004.
Disclosures: The Australian Research Council and the National Health Medical Research Council in Australia funded the research. The authors did not report any conflicts of interest.