Updates on Women’s Health Issues in Patients with Inflammatory Bowel Disease

Purpose of review

Inflammatory bowel disease affects approximately 800,000 women in the USA with the peak incidence between ages 15 to 40. Thus for many females, IBD can impact nearly every stage of their life from menarche to pregnancy, menopause, and beyond. This paper will review the most recent updates on the topics of sexual health, cervical cancer screening, menstruation, fertility, contraception, and menopause.

Recent findings

Menarche can be delayed in females especially those who are underweight, malnourished, or with active inflammatory bowel disease. Cyclical GI symptoms during a menstrual cycle are very common in women with IBD and should not be confused with flares. Overall fertility is similar to the general population unless females with IBD have had significant abdominal surgery but reassuringly this infertility appears to be restored with the use of in vitro fertilization. Discussion regarding family planning is imperative in women with IBD with a strong recommendation to consider long-acting highly effective contraceptives such as intrauterine devices or implants. Cervical cancer screening should be tailored in women on immunosuppressive medications and all women under 26 years of age should be advised to receive the human papilloma virus vaccination.

Summary

As gastroenterologists will have longitudinal relationships with their female IBD patients, they must be knowledgeable about sex-specific issues during each stage of life from puberty to after menopause to optimize their patient’s care.

     

Exercise Function of Children with Congenital Aortic Stenosis Following Aortic Valvuloplasty during Early Infancy

Objectives. The objectives of this study were to characterize the exercise function of patients treated with balloon aortic valvuloplasty at ≤6 months of age, and identify factors associated with exercise dysfunction. Background. Balloon aortic valvuloplasty is the primary therapy for neonatal aortic stenosis (AS). Residual and/or acquired abnormalities of left heart structure and function may adversely affect exercise capacity. Methods. We prospectively recruited patients >6 years old with a history of neonatal AS to undergo exercise testing. Results. We enrolled 30 patients (median age 13.1 years) who underwent balloon aortic valvuloplasty at a median age of 12 days. At time of exercise testing, the median maximum Doppler AS gradient was 34 mm Hg (0–70 mm Hg); 11 patients had moderate or severe aortic regurgitation. All patients were asymptomatic. Overall, peak oxygen consumption (VO₂) was below normal (87 ± 18% predicted; P < .001), and was severely depressed (≤70% predicted) in 7 patients (23%). Although peak O₂ pulse was well preserved overall (97 ± 22% predicted; P= .36), 11 patients had an O₂ pulse <85% predicted, including all patients with VO₂≤ 70% predicted. Peak heart rate was below normal overall (91 ± 7% predicted, P < .001), but severe chronotropic dysfunction (≤70% predicted) was rare (n = 1). Age at testing correlated inversely with peak VO₂ (R²= 0.30; P= .002). No other demographic, historical, or echocardiographic variables were associated with peak VO₂. Conclusion. Although exercise function is preserved in most patients with a history of AS treated in early infancy, a subset have markedly reduced peak VO₂, usually because of inability to increase stroke volume.     

The home care crisis of the nineties

The supply of acceptable quality, paid custodial home care is threatened by the increasingly precarious financial condition of providers. Examined were the trends of the publicly-owned, for-profit providers. Restrictive public payments and the lack of private insurance coverage have contributed to the financial woes. Changes are urgently needed which address the financing of home care.     

Exercise thallium-201 myocardial scintigraphy in women: Correlation with coronary arteriography

Results of exercise thallium-201 myocardial perfusion images, obtained in 60 women suspected of having coronary artery disease, were correlated with coronary angiographic findings. Thirty-two patients had no significant coronary artery disease; 28 patients had severe coronary artery disease defined as 70 percent or greater diameter narrowing of one vessel (14 patients) or multiple vessels (14 patients). The exercise electrocardiogram was positive in 17 patients (9 with and 8 without coronary artery disease), negative in 16 patients (3 with and 13 without coronary artery disease) and inconclusive in 27 patients (16 with and 11 without coronary artery disease). The exercise thallium-201 scintigram showed exercise-induced defects (reversible ischemia) in 21 patients with coronary artery disease, a fixed defect in 1 patient with single vessel disease and previous transmural infarction, but was normal in the remaining 6 patients, who had single vessel disease. The exercise thallium-201 scintigram in subjects with no coronary artery disease was normal in 28, showed an exercise-induced defect in 1 subject and a fixed defect in the remaining 3 subjects. These fixed defects involved the anterolateral segment in the anterior projection and are thought to be due to attenuation of activity by the overlying breasts. Thus, the sensitivity of the exercise electrocardiogram was 32 percent and the specificity 41 percent. In contrast, the sensitivity of exercise thallium-201 scintigraphy was 75 percent and the specificity 97 percent if only exercise-induced defects were considered abnormal and 79 and 88 percent, respectively, if all fixed defects were considered abnormal.It is concluded that exercise thallium scintigraphy is useful in women suspected of having coronary artery disease. Attenuation of activity by breasts may affect the specificity but not the sensitivity. The exercise electrocardiogram is neither sensitive nor specific in this group.     

Use of QRS scoring and thallium-201 scintigraphy to assess left ventricular function after myocardial infarction

To determine the usefulness of the QRS scoring system in predicting left ventricular function, and the correlation between the QRS score, left ventricular ejection fraction, and the size of infarction, patients with acute or chronic infarction were studied by means of 12-lead electrocardiography, rest thallium-201 scintigraphy, and radionuclide angiography.

In patients with acute infarction there was a statistically significant correlation between the QRS score and the left ventricular ejection fraction (n = 28, r = −0.61, p < 0.001), between the thallium score (as a measure of the extent of necrosis) and the left ventricular ejection fraction (n = 21, r = 0.70, p < 0.001), and between the QRS score and the thallium score (n = 22, r = −0.65, p < 0.001). A QRS score of 2 or less separated patients with left ventricular ejection fraction of 40% or greater from those with lower left ventricular ejection fraction (p < 0.01).

In patients with chronic infarction there was a wide scatter of ejection fraction for any given QRS score (n = 41, r = −0.51). In a subset of patients with chronic infarction before they underwent coronary artery bypass, there was still a fair correlation between thallium score and left ventricular ejection fraction (n = 15, r = 0.61, p < 0.02) but not between thallium score and QRS score (r = 0.03, p > 0.05). In addition, in these patients with chronic infarction who underwent coronary revascularization, there was still a fair correlation between the postoperative thallium score and the postoperative left ventricular ejection fraction (r = 0.75, p < 0.05) but not between the postoperative thallium score and the postoperative QRS score (r = 0.02, p > 0.05) or between the QRS score and the ejection fraction (r = 0.24, p > 0.05).

The size of the defect appears related to the left ventricular ejection fraction in both patients with acute infarction and those with chronic infarction. The QRS scoring system in patients with acute infarction and the size of the thallium defect in patients with acute or chronic infarction can categorize patients into those who have a low, moderate, and normal ejection fraction.     

Impact of serious mental illness online training for certified nursing assistants in long term care

ABSTRACT

Certified nurse assistants (CNAs) spend the most staff time with nursing home residents, yet they receive little training in addressing the mental health needs of residents with serious mental illness (SMI). Forty CNAs from four long-term-care facilities took the online interactive CARES-^® Serious Mental Illness^? training consisting of two modules guided by the Recovery Movement philosophy of care. Responses from pre–post testing, Likert-type items, and open-ended questions indicated that CNAs gained information, changed their perspectives, and had more confidence in dealing with SMI. Although there were minor concerns regarding length, clarity of content, and technical issues, CNAs found the online format acceptable and easy to use, and many said they would recommend the training. CARES Serious Mental Illness online training appears to be a viable way of helping CNAs address the mental health needs of long term care residents. Additional testing on CARES Serious Mental Illness is planned.     

Complement-induced vesiculation and exposure of membrane prothrombinase sites in platelets of paroxysmal nocturnal hemoglobinuria

Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired stem-cell disorder in which the glycolipid-anchored membrane proteins, including the cell-surface complement inhibitors, CD55 and CD59, are partially or completely deleted from the plasma membranes of mature blood cells. To gain insight into the pathogenesis of thrombosis that is frequently observed in this disorder, the procoagulant responses of PNH platelets exposed to the human terminal complement proteins C5b-9 were investigated. C5b-9 complexes were assembled on gel-filtered platelets by incubation with purified C5b6, C7, C9, and limiting amounts of C8. Platelet microparticle formation and exposure of plasma membrane- binding sites for coagulation factor Va were then analyzed by flow cytometry. PNH platelets exhibiting undetectable levels of surface CD59 antigen showed an approximately 10-fold increase in sensitivity to C5b- 9-stimulated expression of membrane-binding sites for factor Va when compared with platelets from normal controls. Expression of catalytic surface for the prothrombinase complex (VaXa) paralleled the exposure of factor Va-binding sites; the rate of prothrombin conversion by C5b-9- treated PNH platelets exceeded that of C5b-9-treated normal controls by approximately 10-fold at the maximal input of C8 tested (500 ng/mL). These data indicate that PNH platelets deficient in plasma membrane CD59 antigen are exquisitely sensitive to C5b-9-induced expression of prothrombinase activity, and suggest that the tendency toward thrombosis in these patients may be due, at least in part, to the deletion of this complement inhibitor from the platelet plasma membrane.     

The effects of duration of caregiving on institutionalization

PURPOSE: Our objective in this analysis was to determine how the duration of caregiving interacts with key care demands (i.e., severity of problem behaviors) to influence the institutionalization of individuals suffering from dementia. METHODS: We utilized multiregional data from 4,761 caregivers of individuals with dementia over a 3-year period. We conducted multinomial logistic and Cox proportional hazards analyses to determine the moderating effects of duration on behavior problems when institutionalization was predicted. Baseline covariates included the context of care, primary objective stressors, primary subjective stressors, resources, and global outcomes. RESULTS: The Duration of care x Behavior problems interaction term was not significant in the multinomial regression or Cox hazards models. However, main effects models demonstrated that more recent caregivers were more likely to institutionalize individuals with dementia than respondents in different stages of the caregiving career. IMPLICATIONS: The results emphasize the need to (a) broaden scientific conceptualizations to consider duration of care as integral; (b) refine targeting when interventions are administered early in the dementia caregiving process; and (c) understand patterns of attrition when caregiver adaptation is modeled over time.     

The longevity effect of cranberry extract in Caenorhabditis elegans is modulated by daf-16 and osr-1

Nutraceuticals are known to have numerous health and disease preventing properties. Recent studies suggest that extracts containing cranberry may have anti-aging benefits. However, little is known about whether and how cranberry by itself promotes longevity and healthspan in any organism. Here we examined the effect of a cranberry only extract on lifespan and healthspan in Caenorhabditis elegans. Supplementation of the diet with cranberry extract (CBE) increased the lifespan in C. elegans in a concentration-dependent manner. Cranberry also increased tolerance of C. elegans to heat shock, but not to oxidative stress or ultraviolet irradiation. In addition, we tested the effect of cranberry on brood size and motility and found that cranberry did not influence these behaviors. Our mechanistic studies indicated that lifespan extension induced by CBE requires the insulin/IGF signaling pathway and DAF-16. We also found that cranberry promotes longevity through osmotic stress resistant-1 (OSR-1) and one of its downstream effectors, UNC-43, but not through SEK-1, a component of the p38 MAP kinase pathway. However, SIR-2.1 and JNK signaling pathways are not required for cranberry to promote longevity. Our findings suggest that cranberry supplementation confers increased longevity and stress resistance in C. elegans through pathways modulated by daf-16 and osr-1. This study reveals the anti-aging property of widely consumed cranberry and elucidates the underpinning mechanisms.