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  • September 24, 2018 10:00 AM | Anonymous

    September 25, 2018, Medscape 

    Obesity almost doubles the risk for urinary incontinence (UI) in young and middle-aged women compared with women of normal weight, the authors of a new meta-analysis warn.

    These findings are significant because those with a history of even mild UI when young are more likely than women without such a history to have increasingly bothersome symptoms as they grow older, and the longer they have the excess weight, the greater the risk for UI, lead author Tayla Lamerton, a PhD candidate in women's health at the University of Queensland, Brisbane, Australia, and colleagues write.

    The study was published online September 19 in Obesity Reviews.

    Once considered a condition of mostly older or multiparous women, UI, defined as the involuntary loss of urine, has become increasingly prevalent in younger and nulliparous women, leading to a search for causes, Lamerton and colleagues explain. Recent research suggests that overweight and obesity may increase the risk for UI in women, possibly because excess abdominal weight places increased pressure on the bladder, which may, in turn, exceed urethral closure pressure leading to urine leakage.

    They suggest that clinicians "emphasize the role of excess weight on pelvic floor weakening and subsequent risk for incontinence" along with its metabolic risks. In fact, maintenance of a healthy weight could be presented to younger women as a strategy for preventing UI.

    The data support a new clinical guideline from the US Women's Preventive Services Initiative that recommends all women, even adolescents, be screened for UI once a year, although not all experts agree with this recommendation.

    Excess Weight Overshadows Age as a Risk Factor for UI

    In their study, Lamerton and coauthors searched for articles published in English up until September 2017. Inclusion parameters were cohorts with a mean age of 55 years or younger at baseline; excess weight measured using body mass index (BMI), weight, or waist circumference; follow-up of more than 2 years; and use of a risk ratio (RR) estimate of the association between excess weight and UI, among other criteria.

    The final analysis included 14 studies with 47,293 women from eight countries: Australia, France, United States, Denmark, England, Scotland, Wales, and the Netherlands. Most participants came from a single study with a sample size of 30,982.

    Among women who were overweight, defined as a BMI of 25 to 30 kg/m2, the risk for UI was increased by about a third compared with women with a normal BMI (pooled risk estimate, 1.35; 95% CI, 1.20 - 1.53). For women who were obese, defined as a BMI > 30 kg/m2, the pooled risk estimate was 1.95 (95% CI, 1.58 - 2.42), again compared with normal-weight women.

    "Overall," the authors write, "the pooled estimate of the risk for developing UI because of excess weight exposure (overweight plus obesity) was 1.68 (95% CI, 1.47 - 1.92)."

    They did not observe any differences in UI risk between women younger than 36 years of age and those aged 36 to 53 years.

    "This result points to the importance of excess weight, above and beyond age-related risk," they add.

    The authors also determined whether excess weight was associated with an increased risk for any of the four subtypes of UI:

    • Stress UI: Involuntary loss of urine associated with activities such as coughing or sneezing;
    • Urge UI: Urinary leakage associated with or immediately preceded by a feeling of urgency;
    • Mixed UI: A combination of urge and stress UI symptoms; and
    • Severe UI: Urinary leakage of unusually high frequency or amount.

    Of the 14 studies included in the analysis, five provided risk estimates according to these subtypes. In a pooled risk estimate, the risk for mixed UI was 2.45, followed by 2.28 for severe UI, 1.90 for urge UI, and 1.83 for stress UI. These differences were not significant.

    In an overall estimate that combined all subtypes, "excess weight doubled the risk of developing any UI subtype," with an effect size of 2.0 (95% CI, 1.74 - 2.31).

    One major limitation was that only five of the studies adjusted for whether women had ever given birth, meaning the risk estimates may not have been completely independent of parity, the authors write.

    Also, none of the studies categorized participants according to subcategories of obesity, so estimation of UI risk according to severity of obesity was not possible. Also, the analysis was limited to studies published in English and conducted in high-income Western nations.

    UI is a complex issue, especially among younger women, Lamerton said in a news release about the study.

    "Understanding overweight and obesity as a determinant of urinary incontinence could play a role in the way we counsel those affected by the condition, and our findings provide a building block to further explore lifestyle interventions for preventing and managing incontinence," she stressed.

    The authors have reported no relevant financial relationships.

    Obesity Reviews. Published online September 19, 2018. Abstract



  • September 24, 2018 9:58 AM | Anonymous

    September 25, 2018, HealthDay News  

    Molecular markers of breast cancer tumors can be identified by focusing on parameters of a cell's nucleus, and aided by machine learning, according to a study published online Sept. 4 in npj Breast Cancer.

    Rishi R. Rawat, from the University of Southern California in Los Angeles, and colleagues introduced a machine learning framework to identify relationships between cancer tissue morphology and hormone receptor pathway activation in breast cancer pathology samples stained with hematoxylin and eosin (H&E). The authors focused on predicting clinical estrogen receptor (ER) status from the spatial arrangement of nuclear features as a proof-of-concept. To predict ER status, the learning pipeline extracted parameters describing the position, shape, and orientation of the nuclei from H&E images, and passed them to a deep neural network.

    The researchers found that the pipeline predicted ER status in an independent test set of 56 patient samples after training on 57 tissue cores of invasive ductal carcinoma (area under the receiver operator characteristic curve, 0.72). Machine-derived descriptors of morphologic histology patterns were correlated to signaling pathway status.

    "We can use this technology to identify the molecular markers of the tumor and in the future will identify which therapeutics the tumor will respond to," Rawat said in a statement. "Machine learning helps us get this information to patients sooner and may transform cancer care in the developing world where precise breast cancer marker assessment is in short supply."

    Abstract/Full Text (subscription or payment may be required)



  • September 21, 2018 7:40 AM | Anonymous

    September 21, 2018, HealthDay News  

    Risk of cardiotoxicity is higher for patients receiving trastuzumab and/or anthracyclines for the treatment of breast cancer, according to a study published in the Aug. 1 issue of JACC: Cardiovascular Imaging.

    Mariana L. Henry, from the University of Texas MD Anderson Cancer Center in Houston, and colleagues used data from the Truven Health MarketScan (IBM Watson Health, Cambridge, Mass.) database to assess the rate of chemotherapy-related cardiotoxicity and to estimate adherence to recommendations for cardiac monitoring among 16,456 breast cancer patients (median age, 56 years) treated with chemotherapy (2009 to 2014).

    The researchers found that cardiotoxicity was identified in 4.2 percent of patients. There was an increased risk of cardiotoxicity associated with therapy with trastuzumab (hazard ratio, 2.01) and anthracyclines (hazard ratio, 1.53), Deyo comorbidity scores (hazard ratios, 1.38 for scores of 1 and 2.47 for scores ≥2), hypertension (hazard ratio, 1.28), and valve disease (hazard ratio, 1.93). Younger patients (≤35 years of age and 36 to 49 years) had lower risk of cardiotoxicity versus patients ≥65 years (hazard ratios, 0.37 and 0.49, respectively). Guideline-adherent cardiac monitoring was identified in 46.2 percent of patients treated with trastuzumab.

    "Cardiac monitoring among trastuzumab-treated patients should be a priority among high-risk patients and in the presence of comorbidities or other chemotherapies such as those using anthracyclines," the authors write.

    One author disclosed financial ties to the pharmaceutical industry.



  • September 12, 2018 9:20 AM | Anonymous

    Women's Health Update 2018 
    Presented by Essential Access Health & Contraceptive Technology   

    October 24-25, 2018, Los Angeles, CA 

    REGISTER TODAY to attend Women's Health Update 2018, including hands-on clinical training sessions on the latest methods and techniques for contraceptive care. The clinical trainings will be provided by nationally recognized experts in the field. Learn more.


  • September 07, 2018 8:27 AM | Anonymous

    Offered via the Association of Reproductive Health Professionals (ARHP)  

    Description: 

    According to the CDC, in 2015, there were an estimated 38,500 new HIV infections, down from 41,800 in 2010. While great progress has been made in preventing and treating HIV, there is still much work to be done. This two-webinar series examines clinical providers’ vital role in HIV prevention.  

    Webinar 1:

    HIV Prevention: Frontline Providers' Role in

    "Getting to Zero"

    September 25th at 4pm EDT

    After this webinar, you will be able to:

    • Summarize current epidemiology of HIV in the U.S.
    • Describe three national frameworks for preventing new HIV infections
    • Summarize current guidelines for HIV screening
    • Explain the current guidelines for initiation of antiretroviral treatment for people living with HIV
    • Apply guidelines and patient-centered communication techniques to a case study 

    Webinar 2:

    HIV Prevention in the Clinical Setting

    November 1st at 2pm EDT

    After this webinar, you will be able to:

    • Summarize current epidemiology of HIV in the U.S.
    • Explain current guidelines for HIV screening
    • Describe current guidelines for initiation of treatment for people who test positive
    • Describe the role of pre-exposure prophylaxis (PrEP) in HIV prevention
    • Apply guidelines and patient-centered communication techniques to a case study 



  • September 04, 2018 9:50 AM | Anonymous
    September 4, 2018, Medscape 


    The US Food and Drug Administration (FDA) has approved two new oral treatments for adults with HIV-1 infection, Pifeltro and Delstrigo, both from Merck & Co, according to a company news release.

    Pifeltro contains doravirine (100 mg), a new non-nucleoside reverse transcriptase inhibitor to be given in combination with other antiretroviral medicines.  Delstrigo is a once-daily fixed-dose combination of doravirine (100 mg), lamivudine (3TC; 300 mg), and tenofovir disoproxil fumarate (TDF; 300 mg).

    Both drugs are indicated for the treatment of HIV-1 infection in adults with no prior antiretroviral treatment history and are taken once daily with or without food.

    The FDA approved doravirine on the basis of the phase 3 DRIVE-FORWARD clinical trial, in which 766 patients with no antiretroviral treatment history were randomly assigned to once-daily treatment with doravirine or darunavir 800 mg plus ritonavir 100 mg (DRV+r), each in combination with emtricitabine (FTC)/TDF or abacavir (ABC)/3TC.

    Treatment with doravirine led to sustained viral suppression through 48 weeks, meeting its primary endpoint of noninferiority compared with DRV+r, each in combination with FTC/TDF or ABC/3TC.

    At week 48, 84% of the doravirine group and 80% of the DRV+r group had plasma HIV-1 RNA of less than 50 copies/mL.

    Of the 20% of study participants with a high viral load at baseline (HIV-1 RNA > 100,000 copies/mL), 77% in the doravirine group and 74% in the DRV+r group achieved HIV-1 RNA of less than 50 copies/mL at week 48.

    The rate of therapy discontinuation due to adverse events was low in both groups (2% in the doravirine group and 3% in the DRV+r group). Clinical adverse reactions of all grades occurring in at least 5% of participants in the doravirine group included nausea (7%), headache (6%), fatigue (6%), diarrhea (5%), and abdominal pain (5%). No adverse reactions of grade 2 or higher occurred in 2% or more of participants treated with doravirine.

    The doravirine/3TC/TDF combination pill was approved on the basis of data from the phase 3 DRIVE-AHEAD trial, in which 728 patients naive to antiretroviral therapy were randomly assigned to once-daily treatment with doravirine/3TC/TDF or efavirenz (EFV)/emtricitabine/tenofovir disoproxil fumarate (EFV 600 mg/FTC 200 mg/TDF 300 mg).

    The doravirine/3TC/TDF combination provided sustained viral suppression through 48 weeks, meeting its primary endpoint of noninferiority compared with EFV/FTC/TDF.

    At week 48, 84% of the doravirine/3TC/TDF group had plasma HIV-1 RNA of less than 50 copies/mL, as did 81% of the EFV/FTC/TDF group.

    Of the 21% of patients with a high viral load at baseline (HIV-1 RNA > 100,000 copies/mL), 77% in the doravirine/3TC/TDF group and 72% in the EFV/FTC/TDF group achieved HIV-1 RNA of less than 50 copies/mL at week 48.

    A statistically significantly lower proportion of doravirine-treated patients reported neuropsychiatric adverse events in the three prespecified categories of dizziness (9% vs 37%), sleep disorders and disturbances (12% vs 26%), and altered sensorium (4% vs. 8%).

    The rate of discontinuation of treatment due to adverse events was lower with doravirine/3TC/TDF than with EFV/FTC/TDF (3% vs 6%). Clinical adverse reactions of all grades occurring in at least 5% of patients in the doravirine group included dizziness (7%), nausea (5%), and abnormal dreams (5%). No adverse reactions of grade 2 or higher occurred in 2% or more of patients treated with doravirine.

    Both of the new drugs "are contraindicated when co-administered with drugs that are strong cytochrome P450 (CYP)3A enzyme inducers as significant decreases in doravirine plasma concentrations may occur, which may decrease the effectiveness of Delstrigo and Pifeltro. Delstrigo is contraindicated in patients with a previous hypersensitivity reaction to 3TC," the company said in its news release.

    "As a result of the remarkable strides made in the fight against HIV, clinicians and their patients have the opportunity to work together to identify treatment regimens that may be best for each individual, taking into account other aspects of that person's health, including other medicines they may be taking," David Wohl, MD, from the AIDS Clinical Trials Unit at the University of North Carolina at Chapel Hill, said in the release. "Today's approvals of Delstrigo and Pifeltro provide two new options for the treatment of HIV-1 in appropriate treatment-naive adult patients."

    Merck said it anticipates that both drugs will be stocked through wholesalers within 1 month.


     
  • August 30, 2018 2:07 PM | Anonymous

    August 30, 2018, MedPage Today 

    Sexually transmitted disease (STD) diagnoses have increased every year since 2013, with the number of new STD diagnoses the highest ever in 2017, CDC researchers found.

    There were 2.3 million cases of chlamydia, gonorrhea, and syphilis diagnosed in 2017, with syphilis diagnoses up by 76% and gonorrhea diagnoses up by 67% since 2013, according to preliminary data released by the CDC at the National STD Prevention Conference in Washington.

    At a press briefing, Gail Bolan, MD, director of the CDC division of STD prevention, characterized this as a "continuation of a persistent and troubling trend," particularly noting that rates of diagnosis for gonorrhea "nearly doubled" among men and increased one-fifth among women, "something we haven't seen in a long time," she added.

    The CDC reported that chlamydia remained the most common condition reported to the CDC, with more than 1.7 million cases diagnosed in 2017, with a little under half among women ages 15 to 24.

    Bolan cited another troubling statistic about the looming threat of antibiotic resistance regarding gonorrhea treatment. The CDC currently recommends a two-dose therapy for gonorrhea consisting of an intramuscular dose of ceftriaxone -- the only "highly effective" antibiotic used to treat gonorrhea in the U.S. -- and oral azithromycin.

    But Bolan reported that a "small, but growing fraction" of lab specimens of gonorrhea are showing "signs of antibiotic resistance." While she added that there has never been a "confirmed treatment failure" when using this recommended treatment, the worry is there may eventually be a strain of gonorrhea that does not respond to ceftriaxone.

    "Our nation urgently needs new treatment options for gonorrhea," Bolan said. "But CDC alone cannot turn the tide on rising STDs. It requires new commitment from the healthcare sector, scientists, industry, state and local health departments."

    "Commitment" usually means "money," and state and local health officials spoke candidly about the country's "eroding public health infrastructure" that they felt contributed to the tremendous increase in STDs. Specifically, officials cited years of cutbacks in funding for STD prevention, with state and local health departments who rely on federal funding to support their STD programs, working with budgets that are half of what they were 15 years ago.

    "We maintain our bridges and roads, and we see them on TV when they crumble. You don't always see a crumbling public health infrastructure," said Michael Fraser, PhD, executive director, Association of State and Territorial Health Officials (ASTHO). "We know what works with STD prevention. We just don't want to pay for all of it."

    David C. Harvey, MSW, executive director, National Coalition of STD Directors, called for an additional $70 million in funding to "immediately arm state and local health programs to combat this crisis." He said that treatment for STDs costs more than $16 billion a year.

    "It is time that President Trump and Secretary Azar declare STDs in America a public health crisis," adding that emergency access to funding is also needed to bring these rates down.

    In addition to cutbacks in federal and state funding, Harvey cited other factors for the rise of STDs in America, namely the "extreme lack of awareness and education about STDs and sexual health." But he also said providers and patients played a significant role as "doctors are not screening and testing for STDs and patients don't know they need to ask for screening and treatment."

    Bolan added that screening needs to be "routine care" and that providers and patients need to be having that conversation about testing.

    Harvey added a plea to Congress for more funding for provider training, through the CDC STD Prevention Training Centers, where funding has also been cut over the last 20 years.

    But Fraser pointed out that the solution to the rising STD problem is not going to be "treating our way out of it," and that a solid public health infrastructure is also needed. He specifically noted that cuts in funding have affected programs that support "disease investigators," who meet with individuals, talk about their sexual behavior, do contact tracing, and try to prevent future infections.

    "Expecting a physician in an already hurried day-to-day practice to do a slew of [recommended STD testing] is probably not realistic, given the way physicians practice," he said. "Public health can take some of the pressure off the clinical system. You don't need a medical degree to prevent an STD -- you need to talk with people about using condoms."

    Bolan said that the full 2017 STD surveillance report is expected to be released in late September.


  • August 29, 2018 9:00 AM | Anonymous

    APAOG members may view recorded webinars at anytime. Please check out our latest addition, "When Sex Hurts: Identifying and Treating the Causes of Sexual Pain: presented by Alyse Kelly-Jones, MD.

    Click here to view the webinar library. *Must be logged in to view webinar library. 


  • August 28, 2018 9:30 AM | Anonymous
    August 28, 2018, JAAPA 


    Evaluating patients for infertility is common in the primary care setting and can involve multiple differentials and treatment options. This case report describes a 34-year-old woman whose infertility evaluation led to the diagnosis of a pituitary adenoma. 

    Read the full article here.

  • August 23, 2018 9:13 AM | Anonymous

    August 23, 2018, MedPage Today 

    Routine screening for cervical cancer substantially reduces disease incidence and mortality for average-risk women ages 21 to 65, and the benefits outweigh the harms, the U.S. Preventive Services Task Force (USPSTF) concluded in a final guidance statement on the issue.

    The recommendations encompassed multiple screening strategies. The task force concluded "with high certainty" that the benefits of screening women ages 21 to 29 every 3 years with cytology alone (Pap test) "substantially outweigh the harms." The USPSTF panel also concluded that screening every 3 years with a Pap test alone, every 5 years with high-risk human papillomavirus (hrHPV) DNA testing alone, or every 5 years with both tests (cotesting) provides benefits that outweigh the harms for women ages 30 to 65.

    The final recommendations differed from the draft guidance, published in September 2017, by recognizing cotesting as an acceptable screening option. However, cotesting every 5 years for women 30 to 65 is identified as an "alternative" to the "preferred" strategies of cervical cytology or hrHPV testing alone.

    "Women should choose which strategy is right for them after a discussion with their clinician," according to a statement from the USPSTF.

    The task force's review of evidence showed that women younger than 21 or older than 65 do not benefit from screening, provided that women at the upper end of the age range were adequately screened in the past.

    The recommendations, published in JAMA, apply to women with an intact cervix, irrespective of sexual history, but do not apply to women with a history of cervical cancer or precancerous cervical lesions.

    "Screening for cervical cancer saves lives and identifies the condition early when it is treatable," said task force member Carol Mangione, MD, of UCLA. "There are several effective screening strategies available, so women should talk to their doctor about which one is right for them."

    Added panelist Melissa Simon, MD, of Northwestern University's Feinberg School of Medicine in Chicago: "Most cases of cervical cancer occur in women who have not been regularly screened or appropriately treated. That's why it's important for women to be screened regularly throughout their lifetime and receive follow-up and treatment when needed."

    The authors of an accompanying editorial lauded the USPSTF for including cotesting as an option for cervical cancer screening.

    "The USPSTF has shown a high degree of responsiveness to the concerns of clinicians and patients about cotesting," wrote Lee Learman, MD, PhD, of Florida Atlantic University in Boca Raton, and Francisco Garcia, MD, of the University of Arizona in Tucson.

    "The current USPSTF recommendation statement preserves the greatest range of choices for practitioners and patients; in that sense, both will benefit," the editorial added.

    The recommendations have the effect of achieving "an unprecedented degree of concordance across recommendations from a variety of professional organizations," Learman and Garcia continued. The USPSTF, American College of Obstetricians and Gynecologists (ACOG), American Cancer Society/American Society for Colposcopy and Cervical Pathology (ASCCP)/American Society for Clinical Pathology, and (to a lesser extent) the Women's Preventive Services Task Force of the Institute of Medicine "all arrived at very similar recommendations."

    The author of a second editorial appearing in JAMA Internal Medicine noted that the USPSTF did not include cost-effectiveness in the review that led to the recommendations. "Although the USPSTF sets the standard for evidence-based recommendations and acknowledges the critical value of high-quality evidence in making recommendations, it might reasonably be asked, where is the evidence of value in cervical cancer screening?" wrote George Sawaya, MD, of the University of California San Francisco.

    Sawaya pointed out that he is leading an ongoing evaluation of cost-effectiveness analyses "to determine the range of reasonable options for cervical cancer screening. Such analyses may inform future screening recommendations."

    He also noted that the USPSTF recommendations differ in two ways from the Society of Gynecologic Oncology (SGO) guidance on the issue: (1) Starting hrHPV testing at age 30, rather than 25, as supported by SGO; and (2) testing at 5-year intervals and not more frequently.

    ACOG, ASCCP, and SGO issued a joint statement, thanking the USPSTF for including multiple screening options in the recommendations and describing the task force guidance as "largely in line" with their own recommendations.

    One or more members of the task force disclosed relationships with Healthwise, the National Area Health Education Center Organization, and the Merck Foundation.

    Sawaya reporting having no relevant relationships with industry.

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