ACOG Refines Fetal Heart Rate Monitoring Guidelines
Washington, DC — Refinements of the definitions, classifications, and interpretations of fetal heart rate (FHR) monitoring methods were issued today in new guidelines released by The American College of Obstetricians and Gynecologists (ACOG). The objective of the guidelines is to reduce the inconsistent use of common terminology and the wide variability that sometimes occurs in FHR interpretations. ACOG’s Practice Bulletin, published in the July 2009 issue of Obstetrics & Gynecology, supports the recommendations of the Eunice Kennedy Shriver National Institute of Child and Health Development workshop* on electronic fetal monitoring (EFM) held in April 2008. The intent of FHR monitoring is to help keep an eye on the status of the fetus during labor and intervene if necessary. There are two main FHR monitoring methods. The most commonly used method is EFM, which detects the fetal heart rate and the length of uterine contractions and the time between them. EFM allows physicians and nurses to measure the response of the fetal heart rate to uterine contractions. A lesser-used method is manual auscultation, which employs either a small handheld Doppler device or a fetoscope (similar to a stethoscope). A normal fetal heart varies between 110 and 160 beats per minute. A heart rate that doesn’t vary or is too low or too high may signal a potential problem with the fetus. “Since 1980, the use of EFM has grown dramatically, from being used on 45% of pregnant women in labor to 85% in 2002,” says George A. Macones, MD, who headed the development of the ACOG document. “Although EFM is the most common obstetric procedure today, unfortunately it hasn’t reduced perinatal mortality or the risk of cerebral palsy. In fact, the rate of cerebral palsy has essentially remained the same since World War II despite fetal monitoring and all of our advancements in treatments and interventions.” One notable update in the guidelines is the three-tier classification system for FHR tracings (print-outs of the fetal heart rate). Category 1 FHR tracings are considered normal and no specific action is required. Category 2 tracings are considered indeterminate. This category requires evaluation and surveillance and possibly other tests to ensure fetal well-being. Category 3 tracings are considered abnormal and require prompt evaluation, according to ACOG. An abnormal FHR reading may require providing oxygen to the pregnant woman, changing the woman’s position, discontinuing labor stimulation, or treating maternal hypotension, among other things. If the tracings do not return to normal, the fetus should be delivered. “Our goal with the ACOG guidelines was to define existing terminology and narrow definitions and categories so that everyone is on the same page,” says Dr. Macones. One of the problems with FHR tracings is the variability in how they’re interpreted by different people. The ACOG guidelines highlight a case in which four obstetricians examined 50 FHR tracings; they agreed in only 22% of the cases. Two months later, these four physicians reevaluated the same 50 FHR tracings, and they changed their interpretations on nearly one out of every five tracings. A meta-analysis study shows that although EFM reduced the risk of neonatal seizures, there is still an unrealistic expectation that a nonreassuring FHR can predict the risk of a baby being born with cerebral palsy. The false-positive rate of EFM for predicting cerebral palsy is greater than 99%. This means that out of 1,000 fetuses with nonreassuring readings, only one or two will actually develop cerebral palsy. The guidelines state that women in labor who have high-risk conditions such as preeclampsia, type 1 diabetes, or suspected fetal growth restriction should be monitored continuously during labor. Practice Bulletin #106, “Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles,” is published in the July 2009 issue of Obstetrics & Gynecology. * In 2008, The Eunice Kennedy Shriver National Institute of Child Health and Human Development partnered with ACOG and the Society
for Maternal-Fetal Medicine to sponsor a workshop focused on EFM.

Migraines with Aura in Middle Age Associated with Late-Life Brain Lesions
Women who suffer from migraine headaches in middle age accompanied by neurological aura (visual disturbances, dizziness or numbness that can precede migraines) are more likely to have damage to brain tissue in the cerebellum later in life, according to a study by researchers at the National Institute on Aging (NIA) of the National Institutes of Health, the Uniformed Services University of the Health Sciences and the Icelandic Heart Association in Reykjavik. Researchers noted that many people have these types of “silent” brain lesions, but their effect on physical and cognitive function in older people is not well studied. The study appears in the June 24, 2009, issue of the Journal of the American Medical Association. The researchers found that women are more susceptible than men to localized brain tissue damage identified on magnetic resonance images (MRI) and that women who reported having migraines with aura were almost twice as likely to have such damage in the cerebellum as women who reported not having headaches. Researchers noted that while the study shows an association in women between migraine and cerebellar tissue damage later in life, the functional significance of such brain changes remains an open question. The cerebellum is located in the lower back side of the brain and is involved in functions such as motor activity, balance and cognition. “This long-term population-based study increases interest in determining whether migraine could be a risk factor for brain lesions with clinical consequences over time,” said NIA Director Richard J. Hodes, M.D. “Further research should help us better understand what these changes may mean for individuals and for brain function with age.” Migraine headaches affect approximately 11 percent of adults and 5 percent of children worldwide and are more common in women than in men. Migraines are often accompanied by extreme sensitivity to light and sound, nausea and vomiting. Some individuals with migraine also experience neurological aura symptoms, including temporary visual disturbances that can appear as flashing lights, zig-zag lines or loss of vision. This study examined migraine headaches in a community-dwelling cohort of older people. Between 1972 and 1986, when participants were middle-aged (average age 50.9), they were asked about type and frequency of headaches. MRI scans of the cortex and cerebellum brain regions were conducted on 4,600 study participants between 2002 and 2006, when participants’ average age was 76.2. Participants were divided into four groups: migraine headache with aura once or more per month, migraine headache without aura, nonmigraine headache and no headache. The researchers found that overall, 17 percent of the women were classified as having migraine headaches, including 10.3 percent with migraine with aura. Only 5.7 percent of men were classified as having migraine. Overall, MRI scans revealed the presence of any brain lesion in 39.3 percent of the men and 24.6 percent of the women. Prevalence of cerebellar lesions in women with migraine with aura was 23.0 percent vs. 14.5 percent for women not reporting headaches. There was no statistically significant difference in prevalence of these lesions in men (19.3 vs. 21.3 percent). “After adjusting for risk factors for cardiovascular disease, transient ischemic attack or stroke in middle age or late life, we found that women who suffered from migraines with aura in middle age had an almost twofold increased risk of brain lesions in the cerebellum later in life,” said Lenore Launer, Ph.D., senior author and chief of the neuroepidemiology section of the Laboratory of Epidemiology, Demography, and Biometry in the NIA’s Intramural Research Program. “We are currently investigating the clinical implications of these brain lesions in this group of individuals. We are also interested in whether this association represents a cause and effect relationship or whether some other factors are responsible for the apparent association. The findings from this study are consistent with those from a previous study conducted in younger people using a similar protocol.” Participants were part of the Reykjavik Study and the Age Gene/Environment Susceptibility-Reykjavik Study (AGES-RS). Originally established to study heart disease in Iceland, the Reykjavik Study includes a random sample of men and women born between 1907 and 1935 and living in Reykjavik at the beginning of the study in 1967. In 2002, AGES-RS continued the Reykjavik Study to examine risk factors, genetic susceptibility and gene-environment interactions in relation to disease and disability in later life. This study was funded by the National Institute on Aging, the Icelandic Heart Association and the Icelandic Parliament. Components of the study were also supported by the National Eye Institute, the National Institute on Deafness and Other Communication Disorders, the National Heart Lung and Blood Institute and the Migraine Research Foundation.(.)

Oppioidi senza ricetta.
SICP -FEDCP : Plauso all’ordinanza di Fazio, ora andiamo avanti con la cultura dell’uso dei farmaci antidolore e la formazione dei medici in questo campo
Oppioidi senza ricetta. SICP -FEDCP : “Plauso all’ordinanza di Fazio, ora andiamo avanti con la cultura dell’uso dei farmaci antidolore e la formazione dei medici in questo campo”. “La tanto attesa ordinanza e’ stata finalmente firmata. E’ un passo avanti significativo nel trattamento dei malati bisognosi di cure palliative”. Lo affermano Francesca Floriani presidente Fedcp (Federazione cure palliative) e Giovanni Zaninetta presidente della SICP (Societa’ italiana cure palliative), in seguito all’annuncio dato dal viceministro Fazio della firma dell’ordinanza che, in attesa di una legge organica, “detabellizza” i farmaci antidolore, ovvero li esclude da quella cerchia di medicinali che richiedono il ricettario ministeriale. “In questi anni abbiamo lavorato nelle varie commissioni perche’ finalmente si potesse raggiungere l’importante obiettivo di rendere piu’ facile la prescrizione degli oppioidi per chi e’ affetto da patologie croniche e degenerative che ne necessitano la somministrazione – continuano Floriani e Zaninetta – abbiamo raccolto in merito anche un consenso popolare che si e’ concretizzato nella raccolta di piu’ di 70 mila firme a sostegno della semplificazione della prescrizione degli oppioidi”. “Riteniamo – aggiungono ancora Floriani e Zaninetta – che debba progredire di pari passo ad atti importanti come questo, anche una piu’ generale cultura che abbia come specifico obiettivo il contrasto di qualsiasi forma di dolore, soprattutto quando non si puo’ piu’ guarire”. Ora questo passaggio importante per le cure palliative, che collocano proprio il trattamento del dolore in un contesto di cura globale della persona va integrato con “una ulteriore e migliore formazione dei medici all’utilizzo di questi farmaci, come gia’ previsto dalla commissione ministeriale per i medici di medicina generale e come ci auguriamo che presto avvenga anche per le altre specializzazioni”. Milano, 16 giugno 2009.

Inibitori di pompa e polmonite intraospedaliera

Fonte: Aifa. L’uso degli inibitori di pompa protonica nei pazienti ospedalizzati si associa a un aumento del rischio di polmonite intraospedaliera. A questa conclusione giungono alcuni ricercatori di Boston, negli Stati Uniti, dopo aver condotto uno studio prospettico di coorte. A partire da gennaio 2004 e fino a dicembre 2007 tutti i pazienti ricoverati al locale Beth Israel Deaconess Medical Center per più di tre giorni entravano a far parte dell’analisi. Per ogni paziente era inoltre disponibile il dato riguardo all’uso o meno di farmaci acido soppressori, cioè inibitori di pompa protonica o anti H2.

In totale sono stati registrati 63.878 ricoveri, nel 52% dei quali ai pazienti era stato somministrato un farmaco antiacido. Si sono verificati in tutto 2.219 casi di polmonite acquisita in ospedale (3,5% del totale dei ricoverati). I soggetti che erano stati trattati con un acidosoppressore avevano una maggiore probabilità di contrarre una polmonite (4,9% rispetto a 2,0%, odds ratio 2,6, limiti di confidenza al 95% da 2,3 a 2,8). Anche dopo correzione il dato rimaneva significativo (odds ratio 1,3, limiti di confidenza al 95% da 1,1 a 1,4). A un’analisi più approfondita però emergeva che l’associazione era significativa solo per gli inibitori di pompa (odds ratio 1,3, limiti di confidenza al 95% da 1,1 a 1,4) e non per gli anti H2 (odds ratio 1,2, limiti di confidenza al 95% da 0,98 a 1,4).
In pratica
L’ampio uso degli inibitori di pompa induce a riflettere sulle loro reali indicazioni nel paziente ospedalizzato. L’associazione emersa nella ricerca statunitense è in linea con alcune segnalazioni riguardo al rischio aumentato di polmonite con questa classe di farmaci. Il consiglio è di prescrivere l’inibitore di pompa solo quando realmente necessario sulla base delle condizioni cliniche del paziente.
Herzig S, Howell M, et al. Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA 2009;301:2120-8.

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