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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

What Your Doctor Is Reading What Your Doctor Is Reading

Update From the Medical Journals: October 2013

October 31, 2013

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.

Most Twin Pregnancies Do Not Require C-Section

Many obstetricians plan a cesarean section (C-section) to deliver twins. But many women having twins are able to deliver vaginally. Is there a medical advantage to having a planned (scheduled) C-section? Apparently there is not, according to a new study.

Researchers randomly assigned 2,800 women who were pregnant with twins into two groups. One group would have a planned  C-section. The other group would plan on a vaginal delivery. A C-section would only be done if a doctor judged it to be safer at the time of delivery. This study did not include women who had low-weight babies, premature deliveries or breech babies. The size of the study is impressive — the 2,800 women were  from 106 medical centers in 25 countries. Results were published October 2 in the New England Journal of Medicine.

The results showed that both groups had very low complication rates (about 2% in both groups). Ninety-one percent of the women in the planned C-section group did indeed  deliver by C-section. Forty-four percent  of women in the  planned  vaginal delivery group also ended up having a C-section ( due to findings or events at delivery). While 44% sounds large,  it is a much lower rate of C-section than occurs today in typical practice. The current rate of C-section for twin pregnancies is 75%. This number has increased by roughly 40% over the past two decades.

Sometimes C-sections are the safest way to deliver a baby. Still, when it's not clearly necessary, a C-section is worth avoiding. It is a significant operation. Risks to the mother include pain, bleeding, infections and a longer recovery. Delivering a baby before natural labor begins (by scheduling a C section) can sometimes put the baby at risk as well. Women who want to deliver twins vaginally should choose a doctor who is experienced with delivering twins this way. Some doctors are out of practice, due to a habit of scheduling all twins by C-section delivery.

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New Inhaler  for Asthma and COPD May Be Coming Soon

Many people with lung disease use multiple treatments and still don't get relief from symptoms such as shortness of breath, coughing and wheezing. But a new inhaler is showing promising results in study volunteers, according to a report in the journal Lancet Respiratory Medicine. The inhaler contains a drug so new that it is called "RPL554." It is in a drug category called "phosphodiesterase (PGE) inhibitors." The report is a summary of several small trials of the inhaler.

Experts suggest that this drug could be one of the best advances in a decade for managing asthma and chronic obstructive pulmonary disease (COPD). The drug seems to relax airways as well as  calm inflammation and neutralize some of the irritant effects from bacteria. COPD patients using the inhaler had a 17% increase in a common airflow measurement, FEV1.  This gives the amount of air that is exhaled in a second. FEV1 is usually quite low in people with COPD. This result makes the treatment look about equally effective to current bronchodilators, such as inhaled albuterol. The new inhaler had similar results in asthma patients who got quick symptom relief. The report is based on testing among 12 COPD patients, 28 asthma patients and 39 healthy volunteers (so that side effects could be better recognized).

There were no important side effects seen. Most experts anticipate that the inhaler will test well for safety in future studies. It will take several years before this medicine is approved by the U.S. Food and Drug Administration (FDA) and made available. There is already a similar drug on the market in pill form. It is called  roflumilast (Daxas and Daliresp). It was approved by the FDA two years ago. Roflumilast can improve breathing, but it is unpopular due to side effects, such as headaches, nausea and diarrhea. The inhaler form of RPL554 is unlikely to cause these side effects, because it is delivered directly to the lungs in a much smaller dose.

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Stem Cell Treatment May Help People with Multiple Sclerosis

An article in the October 5 issue of The Lancet describes how injections with stem cells may be a new way to treat multiple sclerosis (MS). According to the article, 18 studies are either currently recruiting patients or have already reported initial results using this form of treatment.

MS involves a loss of myelin, a coating around nerve cells. It protects the long fiber (or "axon") that connects one nerve cell to another. In patchy areas of the brain, specialized nerve cells called "oligodendrocytes" can fail to produce myelin. Stem cells have been associated with nerve repair and the return of myelin to some diseased areas of the brain.

Stem cells can be harvested and purified from a patient's own blood. A specialized medicine is given first to stimulate the release of stem cells from the bone marrow into the blood. There are several theories about how stem cells may affect myelin production. Bone marrow stem cells seem to enter the brain and somehow provide cues to cells in the nervous system. Researchers think that proteins secreted from the stem cells might "re-activate" oligodendrocytes that have stopped making myelin. A second theory is that proteins released by the bone marrow stem cells might trigger immature cells in the brain to develop into new functioning oligodendrocytes. A final theory is that bone marrow stem cells may actually fuse with cells in the brain. Whatever the mechanism, some patients improve in ways that suggest nerve repair. This is according to experimental studies.

We have a long way to go before we will fully understand the way that bone marrow stem cells interact with brain cells. But the possibility that this might provide a treatment for nerve injury is very, very exciting. If stem cells can trigger nerve repair in MS, this treatment may eventually help people with other degenerative brain diseases, such as Alzheimer's and Parkinson's disease.

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More News In Brief

  • Blood Test May Help Monitor Thyroid Cancer. Thyroid cancer is treatable with surgery and radioactive iodine treatment. But this cancer can recur. New research has identified two specific proteins (called "microRNA" particles) that may help us to treat and monitor thyroid cancer. The most common kind of thyroid cancer, papillary thyroid cancer, contains these two proteins in samples of the cancer. If the microRNA proteins are in high concentration within the cancer sample, this predicts that the cancer will be aggressive. This may help doctors to decide whether or not to treat the cancer with multiple therapies. Also, after a cancer has been treated, watching for these two proteins in the blood appears useful. High levels in the blood can signal a return of cancer. The microRNA tests might eventually allow us to monitor this cancer well enough that we could detect early recurrence. Research describing the proteins was published online October 28 in the journal Cancer.

    Many patients with a history of thyroid cancer are treated with fairly high doses of thyroid hormone — this is to keep the remaining cells from the thyroid gland quiet, and to prevent any remaining cancer from being stimulated to grow. But too much thyroid hormone is bad for bone health and heart health. Maybe with new ways to monitor for recurrence of thyroid cancer, we will eventually feel safe discontinuing this long-term treatment, and we will avoid these side effects. 

  • Radiation Treatment for Breast Cancer Is Linked to Future Heart Trouble. Radiation treatments are an important part of breast cancer treatment. But they expose the heart and lungs to radiation. Heart disease caused by the radiation can become apparent a decade or more after treatment. Some of the problems that can result include pericarditis (inflammation in the sack around the heart), coronary artery disease, valve scarring, heart failure and abnormal heart rhythms.

    Previous studies have shown that radiation to the left side of the chest is particularly likely to result in heart problems. A group of radiation oncologists (cancer specialists)  has identified factors that are most likely to increase heart risks. They published their findings October 28 in JAMA Internal Medicine. They found that having the treatments on the left side was worse than on the right. Receiving the treatments while lying on your back (instead of belly) was found to expose the heart more fully to radiation. And the intensity of the radiation mattered. In addition, having other risk factors for heart disease (including high cholesterol levels, smoking and high blood pressure) seemed to multiply the radiation risks. The authors proposed that women having radiation treatments should receive the safest dose and position possible. They also should take steps to reduce their other risk factors for heart disease during and after their radiation treatments.

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Mary Pickett, M.D., is an associate professor at Oregon Health Science University where she is a primary care doctor for adults. She supervises and educates residents in the field of Internal Medicine, for outpatient and hospital care. She is a Lecturer for Harvard Medical School and a Senior Medical Editor for Harvard Health Publications.

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