 | What Your Doctor Is Reading | | |
Update From the Medical Journals: October 2007
October 31, 2007  By Mary Pickett, M.D.
Harvard Medical School What's the latest news in the medical journals this month? Find out what your doctor is reading. Pregnancy Weight-Gain Guidelines May Change Current guidelines issued by the Institute of Medicine in 1990 say that most women should gain 25 to 35 pounds during pregnancy. The October issue of Obstetrics & Gynecology, however, published three studies that question this practice and support the need for new guidelines. New evidence and the increasing rate of obesity in the United States make it clear that gaining that much weight during pregnancy is actually risky for mom and baby. Two of the studies tracked more than 120,000 pregnancies in Missouri. When researchers compared women who gained small, medium and large amounts of weight, the women who gained less than 15 pounds had fewer cases of preeclampsia (dangerously high blood pressure) and fewer large-for-gestational-age babies. Also, fewer of the women needed to have cesarean sections. Women who gained more than 35 pounds had significantly higher rates of preeclampsia and cesarean sections. These findings were true for women with a normal body mass index prior to their pregnancies as well as for women who were overweight or obese. In fact, obese women who gained no weight during pregnancy had fewer problems at delivery than women who followed the old guidelines. In the third study, Swedish researchers used information from a birth registry to determine safe weight gain limits after taking into account a woman's pre-pregnancy body mass index. They found the fewest complications during pregnancy and childbirth among: - Women with normal or near normal weight before pregnancy (BMI at least 20 but less than 25) who gained 5 to 22 pounds
- Overweight women (BMI at least 25 but less than 30) who gained fewer than 20 pounds
- Obese women (BMI of 30 or more) who gained fewer than 13 pounds.
None of the studies included twin or other multiple pregnancies. More underweight babies were born to women who gained less weight, but this problem was overshadowed by the improved safety overall. Since almost 50% of women in recent years have gained more weight than the generous amounts recommended by the 1990 guidelines, it will be a significant challenge to adjust to new, lower weight guidelines once they are formalized. Back to top Medicine Helps Treat Alcohol Dependence The seizure medicine topiramate (Topamax) is helpful for treating alcohol dependence, says a study in the October 10 issue of the Journal of the American Medical Association (JAMA). The 371 participants were all heavy drinkers who had been diagnosed with alcohol dependence, and who wanted to stop drinking. Half of the participants were randomly picked to take the study drug, and the other half took a placebo (dummy) pill. The study subjects did not know which pill they were receiving. The participants also attended a counseling session each week to encourage them to avoid excessive drinking. After 14 weeks (nearly 100 days) of treatment, the group that took topiramate drank heavily on 44 of the 100 days (on average) while the placebo group drank heavily on 52 of the 100 days. In addition, more people who took topiramate were able to go four weeks during the study without relapsing into heavy drinking. Considering the fact that all of the study participants were volunteers who wanted to stop drinking, these results show how difficult it is for people to break a pattern of alcohol dependence, even with regular counseling sessions. Topiramate may be a useful treatment to try even though it has modest benefits. Back to top Immediate Treatment After TIA Dramatically Lowers Chance of Stroke The November issue of Lancet Neurology, released online October 15, includes dramatic findings from a study about the importance of quick treatment after a transient ischemic attack (TIA) or "mini-stroke." During a TIA, circulation to a part of the brain is cut off briefly. It causes stroke-like symptoms (slurred speech, dizziness or numbness on one side of the body) that usually go away within 5 to 20 minutes. Unlike a stroke, however, the circulation is quickly restored, which prevents permanent damage to brain cells. A TIA is a clear warning sign that you are at risk for stroke. In fact, your chance of having a stroke may be as high as 10% in the week after a TIA. Most people who have had a TIA can lower their stroke risk with better blood-pressure control, lower cholesterol levels and blood thinning medication (such as aspirin). In separate studies, researchers in England and France tested the effectiveness of an early-treatment program for people diagnosed with a TIA to reduce the chances of a future stroke. Normally it can take about three weeks for patients to see their regular doctors and have their medications adjusted. French researchers enrolled 1,085 people in a program that provided immediate care and treatment to patients suspected of having a TIA. The British study compared 381 patients who received standard care from their doctors with 281 patients who received quick and early treatment for symptoms in special clinics. Patients in both studies received the same treatment: aspirin, clopidogrel (a blood thinner given to certain patients), blood pressure medication to lower systolic blood pressure below 130, warfarin (Coumadin) for people with atrial fibrillation, and cholesterol-lowering medicine. They also checked patients' carotid arteries by ultrasound to see who needed cholesterol plaque surgically removed from the carotid artery (carotid endarterectomy) to lower their stroke risk. In both studies, the patients who got immediate care were able to start stroke-prevention treatments within an average of one day. In the British study, one out of every 50 patients in the immediate-care group had a stroke during the next 90 days compared with 1 out of every 10 patients who didn't receive immediate treatment. (This was about an 80% drop in stroke risk.) In France, one out of every 80 patients who received immediate care had a stroke within the next 90 days. Very rapid attention to blood thinning, blood pressure control and care of cholesterol-associated artery disease is important after a TIA. If you suspect your symptoms could be a sign of a TIA, the earlier you see a doctor for care the better. Back to top More News in Brief - Flu Shots Prove Very Helpful To Elderly — A study in the October 4 issue of the New England Journal of Medicine (NEJM) showed how valuable flu shots are for elderly patients. Researchers studied more than 70,000 adults over age 65 who lived in five separate states. (None of the people lived in nursing homes.) Flu-season data from 1990 to 2000 showed that older adults who received a flu shot had a 27% lower risk for hospitalization for pneumonia or flu symptoms and a 48% lower risk of death during the specific flu season in which they were vaccinated. Since only about 65% of older adults receive a flu shot each year, it's important to spread word about the protection flu shots can offer.
- Statins Have Lasting Heart-Protecting Benefits — People who start cholesterol-lowering drugs called statins usually need to take them indefinitely. A study in the October 11 issue of the NEJM showed that statins' ability to lower the risk for heart attack lingers even after a person stops taking them. The study was a follow-up to a cholesterol-treatment study called the West of Scotland Coronary Prevention Study, which was published in 1995. In the original study, 6,595 healthy men were randomly assigned to take the cholesterol-lowering drug pravastatin or a placebo pill. At the end of the five-year study, it was clear that pravastatin reduced deaths from heart attacks. Swedish researchers went back to review the medical records of 91% of the original Scottish study participants. They found that five years after the study ended, less than 40% of men in the statin and placebo pill groups were being treated with a statin. Ten years after the study ended, the risk of heart attack or death from heart attack was 25% lower in the men who took statins during the original 5-year study period — even though most hadn't continued taking a statin once the study ended — compared with the men who took the placebo. Presumably, statin medicines lowered long-term risk by shrinking cholesterol plaques or making them less likely to crack and trigger clots. The researchers suspect that those patients who continued the statin indefinitely probably had the greatest benefit, but they did not collect the information needed to show this in the study.
Back to top Mary Pickett, M.D. is a lecturer for Harvard Medical School and an assistant professor of medicine at Oregon Health & Science University. At OHSU, she is a director of student programs and she oversees teaching of students and medical residents. She practices general internal medicine in Portland, Ore.
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