Signs of maternal sepsis an “obstetric emergency”
THE authors of a new prospective case–control study of maternal sepsis, published in PLOS Medicine, say the research has highlighted a number of important messages for clinical practice in both primary and secondary care. The researchers identified high levels of life-threatening morbidity which they said indicated that pregnant or recently pregnant women with suspected infection needed closer attention than women who were not pregnant. The research found that for each maternal sepsis death in the UK, about 50 women had life-threatening morbidity from sepsis, with the onset of severe sepsis from systemic inflammatory response syndrome occurring “very rapidly”. The study included 365 confirmed cases of severe maternal sepsis and 757 controls from all UK obstetrician-led maternity units over a 1-year period. The incidence of severe sepsis was 4.7 per 10 000 pregnancies, with 71 women (19.5%) developing septic shock and five deaths (1.4%). Genital tract infection (31.0%) was the most common source site, and Escherichia coli (21.1%) the most common causative organism. The researchers found that although severe sepsis was more common following caesarean delivery, women delivering vaginally were at heightened risk of group A streptococcal infection, and those infected with group A streptococcus were at significantly increased risk of progression to septic shock compared with women infected with another organism. They said while E. coli caused the largest proportion of cases of severe sepsis, outcomes were significantly worse for women with group A streptococcal infection. “Antibiotic prescription does not necessarily prevent progression to severe sepsis, and women should be followed up to ensure recovery”, the researchers wrote. “The rapid progression to severe sepsis highlights the importance of following the international Surviving Sepsis Campaign guideline of administration of high-dose intravenous antibiotics within 1 h of admission to hospital for anyone with suspected sepsis. Signs of severe sepsis, particularly with confirmed or suspected group A streptococcal infection, should be regarded as an obstetric emergency and should be routinely included in obstetric emergency training courses.”

Back pain not linked to the weather
AUSTRALIAN research has found that sudden, acute episodes of low back pain are not linked to weather conditions such as temperature, humidity, air pressure, wind direction and precipitation. The case-crossover study in primary care clinics in Sydney, published in Arthritis Care & Research, included 993 consecutive patients with a sudden, acute episode of back pain over a 1-year period. The researchers interviewed participants to gather demographic and clinical data about the back pain episode. They then obtained weather parameters (temperature, relative humidity, air pressure, wind speed, wind gust, wind direction and precipitation) from the Bureau of Meteorology for the entire study period, comparing weather exposures in the case window (when participants first noticed back pain) to exposures in two control time-windows (1 week and 1 month before the case window). They “unexpectedly” found that heavier wind speed 24 hours before increased the risk of back pain but the magnitude of the effect was small and “unlikely to be clinically important”. “There is little published research investigating the effect of the weather on musculoskeletal pain”, the researchers wrote. “Of the two previous case-crossover studies one found no effect of relative humidity, pressure, rain, hours of sun and cloud cover on symptoms of rheumatoid arthritis while the other found that higher wind speed slightly increased the risk of hip fracture but only in a sub-group of participants.” The researchers did acknowledge that a possible explanation for the lack of effect could be Sydney’s temperate climate. “Regions with more extreme weather conditions may present a different result, but further research is needed”, they wrote.

Drug improves fertility for women with PCOS
US research has found that the aromatase inhibitor letrozole is superior to ovulation induction with clomiphene as a treatment for anovulatory infertility in women with polycystic ovary syndrome (PCOS). The double-blind, multicentre trial, published in the New England Journal of Medicine, included 750 infertile women with PCOS aged 18‒40 years who wanted to conceive. Participants were randomly assigned to receive either clomiphene or letrozole, taking the medications for up to five cycles, with increasing dosage each cycle. The researchers found ovulation, conception, pregnancy and live birth were significantly more likely after treatment with letrozole. They wrote that the rate of pregnancy loss, twin pregnancies, the mean pregnancy duration and birthweight, and rates of neonatal complications (including anomalies) did not differ significantly between treatment groups. The women who received letrozole had a higher rate of live births (27.5%) than those taking clomiphene (19.1%), and ovulation rates were significantly higher with letrozole than with clomiphene at each monthly visit. Clomiphene was associated with a significantly higher incidence of hot flashes and letrozole with significantly higher incidence of fatigue and dizziness. The researchers found that birth defects were rare, with similar rates between the two medications and comparable to women who conceived without treatment.

Stress, depression, hostility linked to stroke
A MULTI-ETHNIC study of atherosclerosis has found higher levels of stress, hostility and depressive symptoms are associated with a significantly increased risk of incident stroke or transient ischemic attacks (TIAs) in middle-aged and older adults, and the associations cannot be explained by known stroke risk factors. The population-based cohort study, published in Stroke, included 6749 adults (53% women) aged 45‒84 years from six US cities who had no clinical cardiovascular disease at baseline. Chronic stress, depressive symptoms, trait anger and hostility were assessed with standard questionnaires. During a median follow-up of 8.5 years, 147 strokes and 48 TIAs occurred. The researchers found hazard ratios (HRs) and 95% confidence intervals (CI) indicated significantly elevated risk for the highest-scoring group relative to the lowest-scoring group for depressive symptoms (HR, 1.86; 95% CI, 1.16–2.96), chronic stress (HR, 1.59; 95% CI, 1.11–2.27), and hostility (HR, 2.22; 95% CI, 1.29–3.81). Even after risk factor adjustment, associations remained significant for depression (HR, 1.02; 95% CI, 1.01–1.04), chronic stress (HR, 1.16; 95% CI, 1.02–1.31) and hostility (HR, 1.08; 95% CI, 1.00–1.17). Anger was not significantly related to risk of stroke or TIA (P > 0.10). “Better understanding of important, potentially modifiable stroke risk factors, including stress and negative emotions, is needed given the aging population and increasing burden of stroke”, the researchers wrote.

Few families know of advance directives for children
A US prospective, cross-sectional survey of parents and caregivers of children with chronic illness has found only 38.1% had heard of an advance directive (AD). The survey of 307 families, published in Pediatrics, found just 27 parents or caregivers (8.8%) had an AD or living will of their own, with only eight (2.6%) reporting that their chronically ill child had an AD. However, 151 participants (49.2%) reported they would be interested in creating an AD for the child, with families that had more frequent emergency department visits in the previous year significantly more likely to express interest. The researchers wrote that the limited AD experience and knowledge of parents and caregivers of children who had chronic illness, and their interest in creating an AD, suggested an unmet need among families of children with chronic illness, “and an opportunity to enhance communication between families and medical teams regarding ADs and end-of-life care”. They wrote that their findings were consistent with existing literature, which described a poor understanding of ADs among the general US adult population. “Although only a small fraction of children in our study population had an AD, close to one-third of patients studied had a medical care plan or advance care guidelines”, they wrote. “It is possible that many of the children in our study had basic medical plans that described their daily care, but did not address decision-making for critical end-of-life circumstances.” The researchers said the results should encourage advancement in the field of paediatric palliative care.

HPV vax not linked to VTE
A STUDY of more than 1.6 million Danish women and girls aged 10‒44 years between 2006 and 2013 has found no association between the quadrivalent human papillomavirus (HPV) vaccination and venous thromboembolism (VTE) during the 42 days following vaccination. The research, published in JAMA, included 500 345 women (31%) who received the HPV vaccine. The study included information on vaccination, use of oral contraceptives, use of anticoagulants, and the outcome of a first hospital diagnosis of VTE not related to pregnancy, surgery or cancer. “Our results, which were consistent after adjustment for oral contraceptive use and in girls and young women as well as mid-adult women, do not provide support for an increased risk of VTE following quadrivalent HPV vaccination”, they wrote. The researchers wrote that a previous analysis of the Vaccine Adverse Event Reporting System database which found disproportionately high reporting of VTE following vaccination was based on a passive surveillance system, and a study using the Vaccine Safety Data link that reported a doubling of VTE risk included few vaccinated cases, many with known risk factors for VTE.

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