Pregnant Women Should Take Greater Care of Novel H1N1 (“Swine Flu”) Virus

A recent study indicates that pregnant women are more severely impacted by a new H1N1 flu virus and should seek immediate treatment with antivirals.

Pregnant women infected with 2009 novel H1N1 had a higher rate of hospitalization and greater risk of death than the general population due to the H1N1 flu.

The data collected and analyzed by the Centers for Disease Control and Prevention (CDC) are the most comprehensive available to date on the impact of this novel H1N1 flu virus among pregnant women.

“The death of a pregnant woman is always heartbreaking, and unfortunately we have been hearing reports of otherwise healthy women dying from H1N1. If a pregnant woman feels like she may have influenza, she needs to call her healthcare provider right away,” said CDC′s Dr. Denise Jamieson, lead author of the study. “Clinicians who treat pregnant women should have a system in place for triaging pregnant women with influenza-like symptoms and they should not delay in initiating appropriate antiviral therapy. Some clinicians hesitate treating pregnant women with antiviral medications because of concerns for the developing fetus, but this is the wrong approach. It is critical that pregnant women, in particular, be treated promptly. ”

Six deaths of pregnant women with H1N1 were reported to CDC between April 15 and June 16, 2009, representing 13 percent of the total 45 deaths reported to CDC during that time period. All were healthy prior to infection of H1N1 and subsequently developed primary viral pneumonia leading to acute respiratory distress requiring mechanical ventilation. All pregnant women who died did not receive antivirals soon enough to benefit their treatment. CDC recommends that pregnant women with suspected or confirmed influenza infection receive prompt treatment with antiviral medication.

Based on past influenza pandemics and on seasonal influenza epidemics, pregnant women have increased rates of illness and death from influenza infection.

Despite recommendations from the Advisory Committee on Immunization Practices and the American College of Obstetricians and Gynecologists for inactivated flu vaccine for all pregnant women, seasonal flu vaccine coverage among pregnant women is very low (less than 14 percent).

Source: Centers for Disease Control (CDC), July 29, 2009; Lancet, August 8, 2009.

Sun Exposure May Trigger Auto Immune Disease in Women

Ultraviolet (UV) radiation from sunlight may be associated with the development of certain autoimmune diseases, particularly in women, according to a study by researchers at the National Institute of Environmental Health Sciences (NIEHS), part of the National Institutes of Health.

“This study found that women who lived in areas with higher levels of UV exposure when they developed an autoimmune muscle disease called myositis were more likely to develop the form known as dermatomyositis, which weakens the muscles and causes distinctive rashes, instead of the form called polymyositis that does not have a rash,” said Frederick W. Miller, M.D., Ph.D., chief of the Environmental Autoimmunity Group, Program of Clinical Research, at NIEHS. “Although we have not shown a direct cause and effect link between UV exposure and this particular autoimmune disease, this study confirms the association between UV levels and the frequency of dermatomyositis that we found in a previous investigation,” said Miller.

The study, published in the August issue of Arthritis & Rheumatism, is also the first to evaluate and find a possible UV radiation association in autoimmune diseases in women.

According to Miller, women are more likely than men to develop many autoimmune diseases, but the reasons for this have not been clear. “We only found the association between UV exposure and dermatomyositis in women and not in men, and it could be that inherent differences in how women and men respond to UV radiation may play a role in the development of certain autoimmune diseases,” said Dr. Miller. Miller also noted that other researchers have shown that female mice develop more skin inflammation after UV light exposure compared to male mice and these effects may be related to the new findings in dermatomyositis.

The study was designed to determine if there was a relationship between the level of UV exposure at the onset of the disease and the type of myositis and autoantibodies that people developed. Dermatomyositis and polymyositis are the two major forms of myositis and both are considered autoimmune diseases, in which the body’s immune system attacks muscle or skin and sometimes other tissues. Dermatomyositis is typically accompanied by a distinctive reddish-purple rash on the upper eyelids or over the knuckles and is often made worse with sun exposure.

To conduct the study, the NIEHS researchers collaborated with myositis centers across the country that had seen 380 patients who had been diagnosed with dermatomyositis or polymyositis and determined their autoantibodies. “Patients with autoimmune diseases make a variety of autoantibodies that are unique to different conditions. One autoantibody specifically associated with dermatomyositis is called the anti-Mi-2 autoantibody and we know from our previous research that UV radiation increases levels of the Mi-2 protein that this autoantibody binds to,” said Miller.

In addition to finding an association between the level of UV radiation and the proportion of women who developed dermatomyositis compared to polymyositis, the researchers found an association between UV levels and the proportion of women with the anti-Mi-2 autoantibody. “More research is clearly needed to understand the potential links between UV radiation and the development of autoimmune diseases and autoantibodies in women,” said Miller.

“While the causes of autoimmune diseases are not known, we suspect from emerging research that they develop after one or more environmental exposures in genetically susceptible people,” said NIEHS Director Linda Birnbaum, Ph.D. “This study adds UV radiation to the growing list of environmental exposures possibly important in the development of autoimmune diseases.”

Source: National Institute of Environmental Health Sciences (NIEHS), July 30, 2009

Sports and Exercise Reduces Breast Cancer Rates

Women who actively participate in sports are 25% less likely to get breast cancer, though the benefits are not seen in obese women, and lean women see the lowest breast cancer rates.

The type of activity undertaken, at what time in life and the woman’s body mass index (BMI) will determine how protective the activity is against the disease.

The researchers reviewed the literature and analysed 62 studies looking at the impact of physical activity on breast cancer risk. They then examined the findings to find out how breast cancer risk appeared to be affected by type of activity, intensity of activity, when in life the activity was performed and other factors.

They found the most physically active women were least likely to get breast cancer. All types of activity reduced breast cancer risk but recreational activity reduced the risk more than physical activity undertaken as part of a job or looking after the house. Moderate and vigorous activity had equal benefits.

Women who had undertaken a lot of physical activity throughout their life had the lowest risk of breast cancer, and activity performed after the menopause had a greater effect than that performed earlier in life.

Physical activity reduced breast cancer risk in all women except the obese and had the greatest impact in lean women (BMI < 22kg/m2)

Women who were mothers, had no family history of breast cancer, were not white and had oestrogen receptor negative tumours also had a reduced risk of breast cancer.

The authors said the way in which physical activity protected against breast cancer was likely to be complex and may involve effects on sex hormones, insulin-related factors, the immune system and other hormone and cellular pathways.

Source: British Journal of Sports Medicine 2008; doi:10.1136/bjsm.2006.029132

Alzheimer’s Disease Risk Different for Men and Women

Recent research suggests that the chances of developing Alzheimer’s Disease are different for men and women, with stroke in men and depression in women being key elements.

The research was conducted in France, among 7,000 people aged 65 and over, drawn from the general population. While none of the participants had dementia, some 40% had mild cognitive impairment. Four years later 6.5% of those displaying mild cognitive impairment had developed dementia, while no change was noted in just over half. About one third returned to normal cognitive ability.

The move from cognitive impairment to dementia however, was marked among subjects taking anticholinergic drugs for depression. A variation in the ApoE gene, a known risk factor for dementia, was also more common among those whose mild cognitive impairment progressed.

The results demonstrated that men with mild cognitive impairment were probably overweight and diabetic, and to have suffered a stroke. In fact, male stroke victims were three times as likely to progress from cognitive impairment to dementia.

Women with mild cognitive impairment had poorer general health, were disabled, and suffered from insomnia, besides having an inadequate support group. They were also unable to perform the daily tasks that would enable them to live alone without assistance. It was judged they were 3.5 times as likely to develop dementia, while those suffering from depression were twice as likely to do so. Stroke was not a risk factor for women, although there was similar rate of occurrence in men and women.

Source: Journal of Neurology, Neurosurgery, and Psychology, 2008; doi 10.1136/jnnp.2007.136903

Obese Women Experience More Aggresive Breast Cancer

Obese women with breast cancer have lower rates of survival, and suffer a more intense form of the disease, according to recently-published research.

"The more obese a patient is, the more aggressive the disease," said Massimo Cristofanilli, MD, associate professor of medicine in the Department of Breast Medical Oncology at The University of Texas M.D. Anderson Cancer Center. "We are learning that the fat tissue may increase inflammation that leads to more aggressive disease."

606 women with breast cancer were observed by Cristofanilli and colleagues, and classified by body mass index into three groups—normal/underweight (24.9 or below), overweight (at least 25 but less than 30), or obese (more than 30). At five years, overall survival was 56.8 percent among obese women, 56.3 percent among overweight women and 67.4 percent among normal weight women. The 10-year survival rate was 42.7 percent among obese women, 41.8 percent among overweight women and 56.5 percent among normal weight women. Researchers found that the rate of inflammatory breast cancer was 45% among obese women, compared with 30% in overweight women, and 15% in women with normal weight.

Obese or overweight women also displayed a higher risk of breast cancer recurrence. Obese women (50.8%) reported a recurrence after 5 years, compared with normal weight women (38.5%). After 10 years, the rate of recurrence was 58% in obese women and 45.4% in women with normal weight.

"Obesity goes far beyond just how a person looks or any physical strain from carrying around extra weight. Particular attention should be paid to our overweight patients," Cristofanilli said.

Drugs commonly used to treat cancer patients, such as tamoxifen, said Dr. Cristofanilli tend to increase weight gain during treatment – an effect physicians should note carefully. "We have actually become quite good at managing acute side effects such as nausea in our chemotherapy patients and it goes away within a couple of days," Cristofanilli said. "Following the nausea, our patients tend to overeat, which further increases their risk of weight gain. We need to implement lifestyle modifications interventions and develop better methods to follow these patients closely."

Clinical Cancer Research, March 15, 2008

Fractured Shoulder May Lead to Higher Incidence of Broken Hip in Older Women

Older women who suffer a broken shoulder (proximal humerus fracture) have a high risk for also breaking a hip within a year after the shoulder injury.

A new study presented today at the 75th Annual Meeting of the American Academy of Orthpaedic Surgeons (AAOS), found that after a shoulder fracture a woman’s risk of fracturing a hip within the following year was five times greater. The risk decreased after the first year but still remained elevated.

Understanding the connection between these injuries is important to preventing hip fractures. Hip fractures account for more than 350,000 hospital admissions in the United States and more than 60,000 nursing home admissions each year. Women have greater risk because of their higher susceptibility to osteoporosis.

Statistics show:

  • about 70 percent of hip fracture patients are women
  • more than 4 percent of hip fracture patients die during their initial hospitalization
  • 24 percent die within a year of the injury
  • about half of women who sustain hip fractures lose the ability to walk independently

Preventing hip fracture poses s a significant quality-of-life issue. "Earlier studies have shown that there is an increased risk of hip fracture after a proximal humerus fracture, but our study found that there is a defined window of time in which the risk is much greater than previously thought. Additionally, other research has shown that interventions within the first three months can reduce the risk of subsequent fractures," said Jeremiah Clinton, MD, co-author of the study and acting clinical instructor at the University of Washington, Department of Orthopaedics. "If we maximize our hip-fracture prevention efforts up front, we may have a much better chance of helping the patient avoid a life-changing and potentially life-ending injury."

The study followed a group of older, Caucasian women for nearly 10 years and found that, while 8 percent of women who did not break a shoulder suffered hip fractures, approximately 14 percent of those who suffered a shoulder fracture later sustained a hip fracture.

The strongest risk factors for hip fracture were age and hip bone mineral density. Other factors included:

  • self-reported health status
  • height at 25 years of age
  • history of recent falls
  • impaired depth perception
  • history of prior fractures

Even when controlling these factors, the researchers still found the increased risk for hip fracture in the first year after a proximal humerus fracture. The reasons for the connection between humerus fracture and hip fracture are still unclear. "It may be associated medical problems, limited use of the injured shoulder, or there could be something about the treatment for the first fracture, such as narcotic pain medications, which could have caused the patient to fall and break a hip," Dr. Clinton said. "Now that we are aware of the relationship between these types of fractures, we can take precautions, intervene early and hopefully help to prevent some hip fractures from occurring."

The Desperate Housewives Result: First Scientific Study Reveals Growing Population Suffer From Eating Disorders in Midlife

The Eating Disorder Center of Denver has announced the results of a two-year study on the growing, but often overlooked population of "middle-aged" women with eating disorders. The study is the first to scientifically establish that there is an increase in the number of women in midlife seeking treatment for eating disorders. It has been a common misconception that the profile of someone with an eating disorder is an upper-class teenage girl. However it is often a woman between the ages of 30 and 65.

"Women with eating disorders who are age 30 and above fly under the radar in terms of getting noticed and treated," said Dr. Tamara Pryor, Clinical Director of the Eating Disorder Center of Denver and the author of this landmark study. "Over the past four years or so, we’ve been seeing more midlife women with eating disorders in our center and according to my research; these women don’t just wake up at age 30 and develop an eating disorder. 94% of the participants had an eating disorder when they were younger and either relapsed or their condition worsened later in life."

"Since such a study has never before been conducted, the results and conclusions drawn from it will have profound effects on how eating disorder treatment is conducted on women in midlife," said Carolyn Ross, MD MPH, medical director of the Eating Disorder Center of Denver. "I am one of the 6 percent for whom the behaviors started later in life. I got a divorce and it started with a diet," said former Eating Disorder Center of Denver patient, Toni Saiber. In a way, I believe I had the temperament traits of someone at risk for an eating disorder [since adolescence], it just hadn’t manifested until I was 32.

"Mid-life eating disorder survivor, Ellen Hart Peña’s illness recurred after the stressor of a divorce. She personally identified with the genetic component of the study’s findings, as her daughter also struggled with the illness. Psychologists refer to personality traits that one has since birth as one’s "temperament." This study is the first to compare the temperament and character profiles of eating disorder patients in adolescence and midlife.

In the study, teen and middle-aged study participants were compared with each other and their profiles were surprisingly similar. Both the midlife eating disorder patients and the young adult eating disorder patients shared genetically-determined traits that resulted in them being highly anxious, worrisome individuals with low self-esteem. "This is about prevention and about intercepting the illness early on. When parents are armed with knowledge about the temperament profile of someone at risk for an eating disorder, they can take steps to prevent it–like never encouraging those children to go on a diet," said Saiber.

"We can change a lot about ourselves, but temperament sticks with you throughout your life. You have to learn what your temperament is in order to make healthy behavior changes that are appropriate for you."

Pryor accounts for the increase in middle-aged eating disorder patients with several explanations:

  • More awareness and better treatment methods have allowed eating disorder patients to survive into middle-age;
  • A baby boom of more middle-aged Americans has likewise yielded a boom of more middle-aged eating disorder sufferers;
  • A society that places such a high premium on a young, very thin physical appearance has caused women to develop eating disorders in adolescence and either relapse or continue their eating disorders well into middle-age

"We call this phenomenon the ‘Desperate Housewives Result’ because of how thin and young the middle-aged women on the popular television show appear. The timely name puts some responsibility on a culture that supports and encourages fountain of youth fixes" said Pryor. "It is just not statistically ‘normal’ for women over 30 to have the same bodies they did at 18 or 20."

Both groups of study participants (regardless of age) shared early dieting as the gateway behavior triggering their illness. Other contributing causes the study identified were: abuse, trauma, grief and loss.

The study found that psychological issues for midlife patients with eating disorders are similar to those in younger women: low self-esteem or self-worth, body loathing and, perhaps, a co-existing psychiatric condition. In fact, women with eating disorders in both age groups were found to have such similar temperaments, coping mechanisms and maturity levels that it does not make sense to separate them from one another in a treatment setting.

"I learned a lot from those young women," Saiber said of her former adolescent therapy group mates. Saiber added that she considers them sisters, sharing the same obstacles in life. "Midlife eating disorder patients may be 46 years old, but this study indicates that they are actually 16 years old, developmentally. Eating disorders actually stunt people’s emotional development," Pryor said. "Both age groups can benefit from one another in treatment."

Fifty more participants have recently been added to this continuing scientific study.

Increased Risk for Heart Disease in Women May Be Linked to Calcium in Coronary Arteries

Some 5% of women rated as low-risk for heart disease show indications of advanced coronary artery calcium, and may be at risk for cardiovascular problems, according to a report in Archives of Internal Medicine.

The standard method for assessing a person’s risk of developing coronary heart disease in the next 10 years is the Framingham risk score, which measures age, cholesterol and blood pressure levels, smoking habits and diabetes. Americans are considered low-risk if their risk is estimated at less than 10% in 10 years, and high risk if the risk is 20% or more in 10 years.

Approximately 95% of American women aged less than 70 are considered low-risk. “Nevertheless”, write the authors, “most women will ultimately die of heart disease, suggesting that the Framingham risk score alone does not adequately identify women in ways that would be useful for targeted preventive interventions”.

Susna G. Lakoski, M.D., M.S., of the Wake Forest School of Medicine, Winston-Salem, N.C., and colleagues measured 3,601 women aged 45 to 84, in 2000. Computed tomographic (CT) chest scans determined scores for coronary artery calcium. High scores pointed to considerable amounts of calcium deposits. Participants were interviewed by telephone every 9 to 12 months about any subsequent cardiovascular diagnoses and hospital admissions.

2,684 (90%) of women were assessed as low-risk by the Framingham score. 32% had detectable calcium in their coronary arteries, while during an average of 3.75 years, 24 of the low-risk women had heart attacks or heart pain, and 34% had a cardiovascular disease event such as heart attacks, stroke or death.

“Compared with women with no detectable coronary artery calcium, low-risk women with a coronary artery calcium score greater than zero were at increased risk for coronary heart disease and cardiovascular disease events,” the authors write. In addition, almost 5 percent of the low-risk women had advanced coronary artery calcium, defined as a score of 300 or greater. These women had a 6.7 percent risk of a heart event and 8.6 percent risk of a cardiovascular event over the 3.75-year follow-up.

The authors believe that these data provide new information on cardiovascular disease risk and the evaluation and treatment of it in middle-aged and older women. They also maintain that women with coronary artery calcium are at potentially higher risk that A Framingham risk score would suggest. Further studies with longer follow-up periods will be required to determine whether women should be screened for coronary artery calcium, or treated more aggressively for heart disease risk factors.

Source: Arch Intern Med. 2007;167(22):2399-2401

HPV Vaccine Not Effective for Treating Genital Warts in Women

For women with human papillomavirus (HPV) infection, use of the HPV-16/18 vaccine will not accelerate reduction of the virus and should not be used to treat the infection, according to a study in the August 15, 2007 issue of JAMA.

HPV vaccines were designed to prevent HPV infection and the development of cervical precancers and cancer. Some research has suggested that HPV vaccines could help clear the virus in women already infected, according to background information in the article.

Allan Hildesheim, Ph.D., of the National Cancer Institute, Bethesda, Md., and colleagues conducted a study to address the question of whether women positive for HPV DNA should be encouraged to receive HPV-16/18 vaccination to induce or accelerate clearance of their infections. The trial was conducted in two provinces of Costa Rica and included 2,189 women age 18 to 25 years who were positive for HPV DNA. Participants were randomly assigned to receive three doses of HPV-16/18 vaccine (n = 1,088) or a control hepatitis A vaccine (n = 1,101) over 6 months.

There was no evidence that HPV vaccination significantly altered rates of viral clearance. At the 6-month visit, rates of clearance were 33.4 percent vs. 31.6 percent for HPV-16/18 among participants who received the HPV vaccine and the control vaccine, respectively. At the 12-month visit, rates of clearance among participants in the HPV group and the control group, respectively, were 48.8 percent vs. 49.8 percent for HPV-16/18.

There was no evidence of vaccine effects with further analysis on selected study entry characteristics reflective of disease extent, including HPV-16/18 antibody results, cytologic results, and HPV viral load. Similarly, no evidence of vaccine effects was observed in analyses stratified by other study entry parameters thought to potentially influence clearance rates and efficacy of the vaccine, including time since sexual initiation, oral contraceptive use, cigarette smoking, and concomitant infection with Chlamydia trachomatis or Neisseria gonorrhoeae.

"These findings have important clinical implications. For example, in countries where HPV DNA testing is incorporated in cervical cancer screening and prevention efforts, adult women who have abnormal Papanicolaou test results induced by HPV infection and/or who test positive for an oncogenic HPV type using the clinically available HC2 test might be interested in receiving the HPV vaccine to treat their existent infection," the authors write. "…our results demonstrate that in women positive for HPV DNA, HPV-16/18 vaccination does not accelerate clearance of the virus and should not be used for purposes of treating prevalent infections."

Source: JAMA. 2007;298(7):743-753.