Treatment of hyperlipidemia in women

Coronary artery disease (CAD) is the most common cause of death in the United States. It is responsible for the deaths of 480,000 people annually. Half of these fatalities are in women. More women die of CAD than due to all cancers combined. The clinical presentation of women with CAD can be very subtle, and atypical as compared to men. Furthermore, women also face a worse prognosis than men following surgical therapy for CAD. Hyperlipidemia is a well-known risk factor for CAD in women, particularly elevated triglycerides and low HDL cholesterol levels. Although estrogen replacement therapy has been considered a primary modality to alleviate some cardiovascular risk in post menopausal women, the results of the recently published HERS trial highlight the need for more research in this field.     

Sickle cell disease in pregnancy

Sickle cell disease (SCD) is a chronic, multisystem disease. Despite decades of medical advances in SCD management, studies have revealed an increased risk of stillbirth, preterm delivery, small for gestational age, maternal mortality and preeclampsia, compared to the general population. Pregnant women with SCD should be cared for within the multidisciplinary team, comprised of specialist obstetricians, high risk midwives and haematologists. A national confidential enquiry into patient outcomes and death (NCEPOD), expressed concerns with a lack of consistent care for SCD patients in pregnancy. Within the UK, there is great geographical variation in the prevalence of SCD, with the highest incidence in large urban, multicultural centres. Trainee obstetricians practising outside of these areas may not gain substantial experience in managing these patients: therefore this review aims to highlight the key antenatal, intrapartum and postnatal elements involved in managing pregnant women with SCD.     

Sudden cardiac death syndrome: diagnosis and management.

Sudden cardiac death (SCD) can be caused by a variety of cardiac and noncardiac disorders. The diagnostic work-up includes detailed history, physical examination, electrocardiography (ECG), chemistry panel, 24-hour Holter ECG recording, and echocardiography. In selected patients, treadmill-exercise testing, electrophysiologic study, cardiac catheterization with coronary angiography, magnetic resonance imaging, and endomyocardial biopsy are performed. The treatment strategy is rationalized according to the underlying disorder and clinical presentation. Correction of reversible causes such as hypoxia, myocardial ischemia, electrolyte imbalance, congestive heart failure, and proarrhythmic effects of drugs is essential. In patients with arteriosclerotic heart disease, coronary revascularization, using percutaneous coronary angioplasty with stenting or aortocoronary bypass grafting, and optimization of hemodynamics are often necessary. For survivors of SCD syndrome (secondary prevention), implantation of a cardioverter/defibrillator (ICD) is the treatment of choice, with or without adjunct antiarrhythmic drug therapy. Reduction of the sympathetic influence such as with beta-adrenergic blockade and control of hypertension or congestive heart failure may abate the triggering mechanism, thereby reducing the rate of arrhythmia reemergence. Because of the ease of the implantation technique and refined programmability, the current trend is to apply ICD therapy in patients deemed at high risk of SCD, with the aim of primary prevention.     

Lessons from RUTH.

The Raloxifene Use for The Heart (RUTH) trial was designed to investigate possible cardioprotective effects of raloxifene in elderly women with coronary artery disease (CAD) or at risk for CAD. While RUTH results demonstrated a neutral effect on CAD risk during 5.6 years of follow-up, they also open a debate whether primary prevention of fractures or breast cancer by raloxifene is justified in view of the serious adverse events which were recorded in this trial. Furthermore, the absolute numbers of saved events (breast cancer and clinical vertebral fractures) or added events (stroke and venous thromboembolism) were in the order of only 1 case per 1,000 treated women/year, a figure which should be evaluated on a pharmacoeconomic scale as well.     

Entrecruzamiento de cordones en la gestación gemelar monocorial monoamniótica

Monochorial monoamniotic twins are at high risk of fetal death due to the general complications seen in multiple gestations, as well as those specific to this type of pregnancy. The most severe complication in these pregnancies is fetal death due to cord entanglement, which occurs in almost all cases.Early ultrasonographic diagnosis and intensive prenatal surveillance are essential for the early detection of cord entanglement and the prevention of fetal death.The need for in-hospital management and the exact gestational age for delivery continue to generate controversy in the literature.     

Kardiovaskuläres Risiko in der Postmenopause und Hormonersatztherapie

More than one third of a woman’s lifetime in the developed countries follows menopause, and the average life expectancy is increasing constantly. With a share of 55%, cardiovascular disease represents the primary cause of death for postmenopausal women. Cardiovascular disease in women manifests at higher age and presents with atypical symptoms. Therefore primary and secondary prevention of cardiovascular disease of postmenopausal women is of increasing interest. Many basic research studies indicate a protective effect of oestrogen for vessels, and several observational studies support these findings. However, randomised controlled studies failed to show secondary prevention of cardiovascular events with oral hormone replacement therapy (HRT). In some studies there was even evidence of increased risk. A trend for primary prevention could be demonstrated only for women with negative cardiovascular anamnesis who obtained oral HRT shortly after menopause. Transdermal oestrogen may be safer with respect to thrombotic risk. When advising patients we must consider our recommendations individually and critically, especially for elderly women with cardiovascular risk.     

Erectile Dysfunction after Sickle Cell Disease–Associated Recurrent Ischemic Priapism: Profile and Risk Factors

IntroductionRisk factors associated with erectile dysfunction (ED) that results from recurrent ischemic priapism (RIP) in sickle cell disease (SCD) are incompletely defined.AimThis study aims to determine and compare ED risk factors associated with SCD and non‐SCD‐related “minor” RIP, defined as having ≥2 episodes of ischemic priapism within the past 6 months, with the majority (>75%) of episodes lasting <5 hours.MethodsWe performed a retrospective study of RIP in SCD and non‐SCD patients presenting from June 2004 to March 2014 using the International Index of Erectile Function (IIEF), IIEF‐5, and priapism‐specific questionnaires.Main Outcome MeasuresPrevalence rates and risk factor correlations for ED associated with RIP.ResultsThe study was comprised of 59 patients (40 SCD [mean age 28.2 ± 8.9 years] and 19 non‐SCD [15 idiopathic and four drug‐related etiologies] [mean age 32.6 ± 11.7 years]). Nineteen of 40 (47.5%) SCD patients vs. four of 19 (21.1%) non‐SCD patients (39% overall) had ED (IIEF <26 or IIEF‐5 <22) (P = 0.052). SCD patients had a longer mean time‐length with RIP than non‐SCD patients (P = 0.004). Thirty of 40 (75%) SCD patients vs. 10 of 19 (52.6%) non‐SCD patients (P = 0.14) had “very minor” RIP (episodes regularly lasting ≤2 hours). Twenty‐eight of 40 (70%) SCD patients vs. 14 of 19 (73.7%) non‐SCD patients had weekly or more frequent episodes (P = 1). Of all patients with very minor RIP, ED was found among 14 of 30 (46.7%) SCD patients vs. none of 10 (0%) non‐SCD patients (P = 0.008). Using logistic regression analysis, the odds ratio for developing ED was 4.7 for SCD patients, when controlling for RIP variables (95% confidence interval: 1.1–21.0).ConclusionsED is associated with RIP, occurring in nearly 40% of affected individuals overall. SCD patients are more likely to experience ED in the setting of “very minor” RIP episodes and are five times more likely to develop ED compared with non‐SCD patients. Anele UA and Burnett AL. Erectile dysfunction after sickle cell disease–associated recurrent ischemic priapism: Profile and risk factors. J Sex Med 2015;12:713–719.     

Operative procedures not involving the heart after percutaneous transluminal coronary angioplasty

The benefit of coronary artery bypass grafting (CABG) in patients with coronary artery disease (CAD) who require extensive surgical procedures not involving the heart has been established. During the past decade, percutaneous transluminal coronary angioplasty (PTCA) has been developed as an alternative therapy to CABG for patients with CAD. In an attempt to determine the safety of other surgical procedures after PTCA, we retrospectively reviewed 148 patients who underwent 193 surgical procedures from four to 1,867 days after PTCA for CAD. Seventy-two patients had surgical treatment within 90 days of PTCA. Thirty-five patients had CABG prior to PTCA, and 113 had PTCA as the initial treatment for CAD. Four patients died postoperatively, only one death was cardiac in origin. One patient had a myocardial infarction postoperatively (the one cardiac death). Fifteen patients had other cardiac complications (nine patients with arrhythmias and six with myocardial ischemia). Patients operated upon within 90 days of PTCA had no increased cardiac morbidity, although the one myocardial infarction occurred in this group. No difference in cardiac morbidity occurred in patients with multivessel CAD treated by PTCA compared with single vessel disease. However, patients more than 60 years of age had more cardiac problems (16 of 110) than those less than 60 years of age (zero of 38) (p = 0.01). Treatment of CAD by PTCA protects the myocardium from fatal cardiac events and myocardial infarction during subsequent noncardiac operative procedures even early (less than 90 days) in the post-PTCA period. Older patients seem to be at higher risk, however, for nonfatal cardiac complications.     

Postpregnancy genital tract and wound infections

Despite the widespread application of standard aseptic techniques during vaginal birth, cesarean birth, and/or termination of pregnancy, postpregnancy infections remain a significant source of maternal morbidity and mortality. Obstetric infection accounts for more than 12% of maternal deaths. Infection occurs most frequently in women who have cesarean births, and following spontaneous or elective termination of pregnancy. Infection is estimated to be the second highest cause of under-reported maternal death in the United States. This article identifies measures to aid in primary prevention and recognition of obstetric infections in order to facilitate early diagnosis and treatment.     

Etiopathogenesis,prediction, and prevention of preeclampsia

Hypertensive disorders are a major cause of maternal death. Preeclampsia (PE) affects about 5% of pregnancies and is associated to high cardiovascular death risk. Understanding of its origin and cause is difficult and many etiologies have been proposed. So far, little can be done for real prevention and the only treatment is pregnancy interruption, increasing the child’s risk for prematurity complications. Early markers of disease are a promising path for understanding the pathogenesis and developing new strategies for prediction and eventually disease prevention.     

Stillbirth: a review.

Stillbirth occurs in nearly 1% of all births in the USA, and is one of the most common but least studied adverse pregnancy outcomes. The many risk factors for and causes of stillbirth are presented. Over the past several decades, the rate of stillbirth has been substantially reduced, with the reduction most apparent in those stillbirths previously occurring at term and/or in labor. Reductions have occurred because of reductions in risk factors (i.e. prevention of Rh disease and better control of diabetes), better antepartum monitoring of those with risk factors followed by early delivery for those fetuses found to be at risk (i.e. growth restriction, maternal pre-eclampsia), better intrapartum fetal monitoring, increases in Cesarean section for those at risk, and early detection of congenital anomalies followed by termination prior to the time that these early fetal deaths are classified as stillbirths. Finally, the value of using fetal autopsy and placental examination to determine the cause of death accurately, both for research purposes and for patient counseling in future pregnancies, is explored.     

Understanding obesity and endometrial cancer risk: opportunities for prevention

Worldwide, obesity has become a major public health crisis. Overweight and obesity not only increase the risk of cardiovascular disease and type-2 diabetes mellitus but also are now known risk factors for a variety of cancer types. Among all cancers, increasing body mass index is associated most strongly with endometrial cancer incidence and death. The molecular mechanisms underlying how adipose tissue and obesity contribute to the pathogenesis of endometrial cancer are becoming better understood and have revealed a number of rational strategies, both behavioral and pharmaceutical, for the prevention of both primary and recurrent disease.     

Prolonged latency of preterm premature rupture of membranes and risk of cerebral palsy*

Objective: To determine whether prolonged latency after preterm premature rupture of membranes (PPROM) is associated with an increased risk of death or moderate-to-severe cerebral palsy (CP).

Study design: This secondary analysis of the randomized controlled trial of magnesium sulfate for the prevention of CP evaluated whether the time interval between diagnosis of PPROM and delivery was associated with increased risk for CP. Prolonged latency was defined as an interval of ≥4 weeks, latency time was also categorized by week of latency for further analysis. The primary outcome was death or moderate-to-severe CP at 2 years of age. Logistic regression was used to control for confounders.

Results: In all, 1522 patients with PPROM were analyzed; of whom, 1328 had a <4-week interval and 194 had an interval of ≥4 weeks. In the unadjusted analysis, the primary outcome was less likely in the PPROM ≥4 weeks group 4.1% versus 8.4%, RR: 0.49, 95% CI: 0.24–0.98. After adjusting for possible confounders, there was no statistical difference associated with PPROM latency ≥4 weeks versus <4 weeks for death or moderate-to-severe CP.

Conclusion: Prolonged exposure to an intrauterine environment of PPROM does not increase risk for CP.     

Third-trimester erythrocytapheresis in pregnant patients with sickle cell disease.

OBJECTIVE: To evaluate the effects of prophylactic transfusion by means of erythrocytapheresis at the beginning of the third trimester of pregnancy in women with sickle cell disease (SCD). METHODS: A cohort of 14 pregnant women with SCD who received prophylactic erythrocytapheresis transfusions at the beginning of the third trimester was retrospectively compared with a cohort of 17 pregnant women who received simple prophylactic transfusions for no indication other than SCD severity. RESULTS: Prophylactic erythrocytapheresis transfusions were associated with a lower risk of intrauterine growth restriction (OR, 0.11; 95% confidence interval, 0.01-1.00) and oligohydramnios (OR, 0.65; 95% confidence interval, 0.45-0.92) in pregnant women with SCD. CONCLUSION: These results suggest that erythrocytapheresis transfusions are beneficial in women with SCD who are in the third trimester of pregnancy. Given the decrease in transfusion risks, this therapy deserves further evaluation in future trials.     

脐带脱垂的预防及处理

脐带脱垂的发生率虽然不高,但这种产科急症与早产、胎儿窘迫、胎死宫内、新生儿窒息、新生儿死亡密切相关,一旦被漏诊或处理不当,就会导致严重的围产儿不良结局。认识脐带脱垂的高危因素并进行积极预防,可有效减少脐带脱垂的发生。一旦发生脐带脱垂,医护的快速反应和团队合作至关重要,减轻脐带压迫措施实施的快慢和终止妊娠时间的早晚是影响新生儿预后的关键。     

1986～2001年武汉市2所综合医院妇科猝死病例的回顾性分析

目的 :调查妇科住院患者的死亡及猝死发生率 ,了解妇科猝死的基本情况。方法 :收集整理 2所综合医院 1 6年来妇科死亡病例 31例和猝死病例 7例 ,按 4个阶段年分别统计分析妇科的死亡及猝死的发生率、猝死与死亡之比 ,探讨妇科死亡及猝死的特点及变化 ,找出猝死病因和病种的构成比及顺位。结果 :1 6年来妇科住院患者的总死亡发生率和猝死发生率分别为 1 3 .1 3/万、2 .96/万。死亡的绝对数和发生率均呈下降趋势。猝死与死亡之比从 1 986～ 1 989阶段年的 7.69% (1 /1 3)上升到 1 998～2 0 0 1阶段年的 50 .0 0 %(2 /4) ,即死亡率的下降程度远远大于猝死率的下降程度。主要猝死原因为心脏性猝死和肿瘤 ;猝死病因及病种的顺位是 :心脏性猝死、肿瘤、异位妊娠等。结论 :妇科住院患者死亡的绝对数和发生率明显下降 ,但猝死的绝对数无下降趋势 ,而且发生率降低较慢 ,虽然治疗技术的进步和认识的提高 ,但猝死的预测及预防仍较困难。猝死的发生机制、病理生理变化等尚有待于深入研究     

Proposition d’une stratégie de prévention du risque fracturaire en début de ménopause

Postmenopausal osteoporosis is a chronic disease, which justifies long-term treatment in those women with an increased risk of fracture. The current disponibility of various drugs, which have demonstrated their efficacy in reducing the incidence of fracture, has raised the question of the best treatment strategy in a woman who would begin her postmenopausal period with an increased risk for fracture. Indeed, for most treatments (with the exception of hormonal replacement therapy [HRT]), their efficacy in reducing the risk of fracture has been mainly demonstrated in higher risk elderly women (above 65 years) with prevalent vertebral fractures. There is uncertainty concerning their cost-effectiveness in younger women for a true primary prevention of the risk of fracture. Furthermore, current guidelines recommend a 5-year period of treatment which has led us to considering treatment strategies which would be based on various sequential treatment periods over time, the selection of each specific sequence being determined by the clinical situation of the woman, the level of her fracture risk and the expected skeletal (in terms of spectrum of bone effects) and potential extraskeletal benefits of drugs. In this regard, HRT or raloxifene, which allows a more global approach of the menopause-induced consequences of estrogen deficiency than the sole prevention of osteoporosis, should be privileged within the first 10 years of treatment or so in those youngest women at increased risk for subsequent fracture. Use of bisphosphonate or strontium ranelate should be thus reserved at a more advanced age, when the prevention of hip fracture becomes mandatory.     

法洛四联症一期根治术后早期死亡危险因素分析

目的 研究与法洛四联症(TOF)一期根治手术早期死亡相关的危险因素。方法 回顾1995年4月至2004年3月在复旦大学附属儿科医院心血管中心行一期根治术的TOF病例152例，术后早期死亡17例，对其术前、术中27个可能的危险因素指标与术后早期死亡的关系进行单因素和多因素分析。结果 单因素分析结果显示与术后早期死亡有关的指标包括：手术时体重、发生青紫年龄、动脉血氧饱和度、升主动脉与肺动脉干直径比AO/MPA 、McGoon比值、Nakata指数、肺体循环血流量之比Qp/Qs 、右向左分流量占体循环血流量比例(Qs-eQp)/Qs 、体肺侧支循环和跨瓣补片。多因素分析结果显示AO/MPA 和McGoon比值与手术早期死亡有关。结论 肺动脉的发育情况是TOF一期根治术后能否生存的关键。手术病例的选择需要综合考虑多种危险因素。 Abstract Objective To identify risk factors associated with early postoperative death in patients undergoing primary repair of tetralogy of Fallot (TOF).Methods 27 preoperative and intraoperative variables potentially predictive of early postoperative death of 152 patients,who underwent primary repair of TOF between April 1995 and March 2004 at the Cardiovascular Center of Children's Hospital of Fudan University,were analyzed in a univariate and multivariate manner.Results Univariate analysis demonstrated a significant association between early postoperative death and the following variables: weight at the time of surgery,age for cyanosis to be present,SaO2,AO/MPA,McGoon ratio,Nakata index,Qp/Qs,(Qs-eQp)/Qs,multiple aortopulmonary collateral arteries and transannular patching. In the multivariate model only AO/MPA and McGoon ratio were associated with early postoperative death.Conclusion Pulmonary artery hypoplasia is the most important risk factor for early postoperative death after primary repair of TOF.Multiple risk factors should be considered when the choice of patients for the procedure is made. Key words Tetralogy of Fallot;Primary repair;Risk factors      

Compliance with mechanical venous thromboproembolism prophylaxis after cesarean delivery

Objective: Universal perioperative mechanical thromboprophylaxis is recommended for patients undergoing cesarean delivery because of increased risk for venous thromboembolism (VTE) associated with this mode of delivery. While research supports clinical benefits from this approach, other specialties have demonstrated suboptimal compliance with prophylaxis device use. The objective of this study was to review patient compliance with sequential compression devices (SCDs).

Methods: This cross-sectional observational study utilized data from a prospective quality assurance analysis to evaluate demographic, medical and obstetrical factors associated with postoperative SCD compliance after cesarean delivery. Observations were performed before 7 a.m. on the first postoperative day, a time point when patients were unlikely to be fully ambulatory and would most benefit from device use. The reason for failure was documented in cases where the device was not being properly used.

Results: Two hundred and ninety-three patients underwent cesarean delivery, had SCD compliance assessed and were included in the analysis. Twenty one percent of patients (n=60) were non-compliant with SCD use. Reasons for noncompliance included patient discomfort, machine malfunction and incorrect device use. Patients who were non-compliant had similar risk factors for thromboembolism compared to women who were compliant.

Conclusion: Although SCD’s are effective in preventing thromboembolism, device use was suboptimal in this cohort of post-cesarean patients. These findings are similar to those from other fields. For institutions that rely primarily on mechanical thromboprophylaxis for obstetric patients, quality assurance and auditing of use may be necessary to ensure patients are receiving adequate prophylaxis. For post-cesarean patients with additional VTE risk factors, pharmacologic prophylaxis may be beneficial.