Myomectomy during cesarean delivery

BackgroundThe optimal management of leiomyomas during cesarean delivery is unclear.ObjectivesTo assess the safety of myomectomy performed during cesarean delivery.Search strategyPubMed, MEDLINE, EMBASE, and Cochrane Library were searched to identify potentially relevant studies published prior to June 30, 2012.Selection criteriaCase‐control study comparing myomectomy with no myomectomy in patients undergoing cesarean delivery.Data collection and analysisThe quality of the studies was assessed and data were extracted independently by 2 authors.Main resultsNine studies, including 1 082 women with leiomyomas, met the inclusion criteria; 443 (41.0%) women underwent cesarean myomectomy and 639 (59.1%) underwent cesarean delivery alone. The drop in hemoglobin after surgery was 0.30 g/dL greater in the cesarean myomectomy group than in the control group, but the difference was not significant. The operative time was 4.94 minutes longer in the cesarean myomectomy group, but again the difference was not significant. The overall incidence of fever was comparable in the 2 groups. No hysterectomies were performed in any of the included studies.ConclusionsCesarean myomectomy may be a reasonable option for some women with leiomyoma. However, no definite conclusion can be drawn because the data included in the meta‐analysis were of low quality.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135417/1/ijgo208.pd

An epidemiological, developmental and clinical overview of cannabis use during pregnancy

The objective of the current narrative literature review is to provide an epidemiological, developmental and clinical overview on cannabis use during pregnancy. Cannabis use in pregnancy poses major health concerns for pregnant mothers and their developing children. Although studies on the short- and long-term consequences of prenatal cannabis exposure are increasing, findings have been inconsistent or difficult to interpret due to methodological issues. Thus, consolidating these findings into clinical recommendations based on the mixed studies in the literature remains a challenge. Synthesizing the available observational studies is also difficult, because some of the published studies have substantial methodological weaknesses. Improving observational studies will be an important step toward understanding the extent to which prenatal exposure to cannabis influences neurodevelopment in the offspring. Therefore, further research on prenatal cannabis exposure and the long-term consequences to offspring health in representative samples are needed to guide and improve clinical care for pregnant women and their children. Future research should also investigate the role of policies on prenatal cannabis use

Lessons learned from the London Exercise and Pregnant (LEAP) Smokers randomised controlled trial process evaluation : implications for the design of physical activity for smoking cessation interventions during pregnancy

BACKGROUND: The challenges of delivering interventions for pregnant smokers have been poorly documented. Also, the process of promoting a physical activity intervention for pregnant smokers has not been previously recorded. This study describes the experiences of researchers conducting a randomised controlled trial of physical activity as an aid to smoking cessation during pregnancy and explores how the effectiveness of future interventions could be improved. METHODS: Two focus groups, with independent facilitators, were conducted with six researchers who had enrolled pregnant smokers in the LEAP trial, provided the interventions, and administered the research measures. Topics included recruitment, retention and how the physical activity intervention for pregnant smokers was delivered and how it was adapted when necessary to suit the women. The focus groups were audio-recorded, transcribed verbatim and subjected to thematic analysis. RESULTS: Five themes emerged related to barriers or enablers to intervention delivery: (1) nature of the intervention; (2) personal characteristics of trial participants; (3) practical issues; (4) researchers' engagement with participants; (5) training and support needs. Researchers perceived that participants may have been deterred by the intensive and generic nature of the intervention and the need to simultaneously quit smoking and increase physical activity. Women also appeared hampered by pregnancy ailments, social deprivation, and poor mental health. Researchers observed that their status as health professionals was valued by participants but it was challenging to maintain contact with participants. Training and support needs were identified for dealing with pregnant teenagers, participants' friends and family, and post-natal return to smoking. CONCLUSIONS: Future exercise interventions for smoking cessation in pregnancy may benefit by increased tailoring of the intervention to the characteristics of the women, including their psychological profile, socio-economic background, pregnancy ailments and exercise preferences. Delivering an effective physical activity intervention for smoking cessation in pregnancy may require more comprehensive training for those delivering the intervention, particularly with regard to dealing with teenage smokers and smokers' friends and family, as well as for avoiding post-natal return to smoking. TRIAL REGISTRATION: ISRCTN48600346 , date of registration: 21/07/2008

Psychosocial interventions for supporting women to stop smoking in pregnancy

Background: Tobacco smoking remains one of the few preventable factors associated with complications in pregnancy, and has serious long-term implications for women and babies. Smoking in pregnancy is decreasing in high-income countries, but is strongly associated with poverty and is increasing in low- to middle-income countries. Objectives: To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes. Search methods: In this sixth update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 November 2015), checked reference lists of retrieved studies and contacted trial authors. Selection criteria: Randomised controlled trials, cluster-randomised trials, and quasi-randomised controlled trials of psychosocial smoking cessation interventions during pregnancy. Data collection and analysis: Two review authors independently assessed trials for inclusion and trial quality, and extracted data. Direct comparisons were conducted in RevMan, with meta-regression conducted in STATA 14. Main results: The overall quality of evidence was moderate to high, with reductions in confidence due to imprecision and heterogeneity for some outcomes. One hundred and two trials with 120 intervention arms (studies) were included, with 88 trials (involving over 28,000 women) providing data on smoking abstinence in late pregnancy. Interventions were categorised as counselling, health education, feedback, incentives, social support, exercise and dissemination. In separate comparisons, there is high-quality evidence that counselling increased smoking cessation in late pregnancy compared with usual care (30 studies; average risk ratio (RR) 1.44, 95% confidence interval (CI) 1.19 to 1.73) and less intensive interventions (18 studies; average RR 1.25, 95% CI 1.07 to 1.47). There was uncertainty whether counselling increased the chance of smoking cessation when provided as one component of a broader maternal health intervention or comparing one type of counselling with another. In studies comparing counselling and usual care (largest comparison), it was unclear whether interventions prevented smoking relapse among women who had stopped smoking spontaneously in early pregnancy. However, a clear effect was seen in smoking abstinence at zero to five months postpartum (11 studies; average RR 1.59, 95% CI 1.26 to 2.01) and 12 to 17 months (two studies, average RR 2.20, 95% CI 1.23 to 3.96), with a borderline effect at six to 11 months (six studies; average RR 1.33, 95% CI 1.00 to 1.77). In other comparisons, the effect was unclear for most secondary outcomes, but sample sizes were small. Evidence suggests a borderline effect of health education compared with usual care (five studies; average RR 1.59, 95% CI 0.99 to 2.55), but the quality was downgraded to moderate as the effect was unclear when compared with less intensive interventions (four studies; average RR 1.20, 95% CI 0.85 to 1.70), alternative interventions (one study; RR 1.88, 95% CI 0.19 to 18.60), or when smoking cessation health education was provided as one component of a broader maternal health intervention. There was evidence feedback increased smoking cessation when compared with usual care and provided in conjunction with other strategies, such as counselling (average RR 4.39, 95% CI 1.89 to 10.21), but the confidence in the quality of evidence was downgraded to moderate as this was based on only two studies and the effect was uncertain when feedback was compared to less intensive interventions (three studies; average RR 1.29, 95% CI 0.75 to 2.20). High-quality evidence suggests incentive-based interventions are effective when compared with an alternative (non-contingent incentive) intervention (four studies; RR 2.36, 95% CI 1.36 to 4.09). However pooled effects were not calculable for comparisons with usual care or less intensive interventions (substantial heterogeneity, I2 = 93%). High-quality evidence suggests the effect is unclear in social support interventions provided by peers (six studies; average RR 1.42, 95% CI 0.98 to 2.07), in a single trial of support provided by partners, or when social support for smoking cessation was provided as part of a broader intervention to improve maternal health. The effect was unclear in single interventions of exercise compared to usual care (RR 1.20, 95% CI 0.72 to 2.01) and dissemination of counselling (RR 1.63, 95% CI 0.62 to 4.32). Importantly, high-quality evidence from pooled results demonstrated that women who received psychosocial interventions had a 17% reduction in infants born with low birthweight, a significantly higher mean birthweight (mean difference (MD) 55.60 g, 95% CI 29.82 to 81.38 g higher) and a 22% reduction in neonatal intensive care admissions. However the difference in preterm births and stillbirths was unclear. There did not appear to be adverse psychological effects from the interventions. The intensity of support women received in both the intervention and comparison groups has increased over time, with higher-intensity interventions more likely to have higher-intensity comparisons, potentially explaining why no clear differences were seen with increasing intervention intensity in meta-regression analyses. Among meta-regression analyses: studies classified as having 'unclear' implementation and unequal baseline characteristics were less effective than other studies. There was no clear difference between trials implemented by researchers (efficacy studies), and those implemented by routine pregnancy staff (effectiveness studies), however there was uncertainty in the effectiveness of counselling in four dissemination trials where the focus on the intervention was at an organisational level. The pooled effects were similar in interventions provided for women classified as having predominantly low socio-economic status, compared to other women. The effect was significant in interventions among women from ethnic minority groups; however not among indigenous women. There were similar effect sizes in trials with biochemically validated smoking abstinence and those with self-reported abstinence. It was unclear whether incorporating use of self-help manuals or telephone support increased the effectiveness of interventions. Authors' conclusions: Psychosocial interventions to support women to stop smoking in pregnancy can increase the proportion of women who stop smoking in late pregnancy and the proportion of infants born low birthweight. Counselling, feedback and incentives appear to be effective, however the characteristics and context of the interventions should be carefully considered. The effect of health education and social support is less clear. New trials have been published during the preparation of this review and will be included in the next update

Managing Maternal Substance Use in the Perinatal Period: Current Concerns and Treatment Approaches in the United States and Australia

Substance use in pregnancy can have adverse effects on mother and fetus alike. Australia and the US are countries with high levels of substance use and policies advising abstinence, although the Australian approach occurs within a broader framework of harm minimization. Less attention has been paid to treatment of the mothers' substance use and what is considered gold standard. This is despite evidence that prior substance use in pregnancy is the most important factor in predicting future substance use in pregnancy. This paper draws together information from both the peer-reviewed and gray literature to provide a contemporary overview of patterns and outcomes of the three main drugs, alcohol, tobacco, and cannabis, used in Australia and the US during pregnancy and discusses what are considered gold standard screening and treatment approaches for these substances. This paper does not set out to be a comprehensive review of the area but rather aims to provide a concise summary of current guidelines for policy makers and practitioners who provide treatment for women who use substances in pregnancy

L’impact de la concomitance de troubles liés à la consommation de substance et de troubles de santé mentale sur les comportements à risque en fonction de l’âge

Objectif : Examiner la relation entre la concomitance de troubles liés à la consommation de drogues (TCD) et d’autres troubles de santé mentale (ATSM) et une vaste gamme de comportements à risque pour le virus de l’immunodéficience humaine (VIH).Méthode : Les données sont tirées d’une étude auprès de 17 141 jeunes âgés de 12 à 25 ans entreprenant l’un de 148 programmes de traitement pour adolescents et jeunes adultes aux États-Unis. On a administré aux jeunes l’Évaluation globale des besoins individuels (questionnaire GAIN) au moment de leur entrée dans leur programme et lors d’au moins une visite de suivi trimestrielle sur une période de 12 mois. Parmi les participants, 90 % étaient des adolescents (âgés de 12 à 17 ans), 10 % étaient en phase de transition (âgés de 18 à 25 ans), 72 % étaient de sexe masculin, 39 % étaient d’origine caucasienne, 16 % étaient d’origine afro-américaine, 26 % étaient d’origine hispano-américaine, 3 % étaient d’une autre ethnie et 16 % étaient pluriethniques. Environ 61 % des autoévaluations respectaient le critère de troubles liés à la consommation de drogues (TCD) et d’autres troubles de santé mentale (ATSM) dans l’année précédente, 18 % respectaient celui de TCD seulement et 10 % d’ATSM seulement. Les caractéristiques démographiques et cliniques des jeunes en phase de transition étaient similaires, quoiqu’un plus haut pourcentage de ceux-ci (25 %) ont déclaré un TCD seulement.Résultats : Dans les deux groupes d’âge, les individus ayant des TCD et d’ATSM concomitants étaient invariablement les plus susceptibles de déclarer les comportements suivants au cours de la dernière année : utilisation de seringues ; partage de seringues ; relation sexuelle non protégée ; multiples partenaires sexuels ; échange de faveurs sexuelles ; partenaires sexuels à risque élevé ; historique de victimisation physique, émotionnelle et sexuelle ; automutilation ; idéation suicidaire ; idées de meurtre ; activités illégales et violence envers les autres. Les jeunes en phase de transition avaient aussi le plus haut taux de visites à l’urgence et un coût pour la société plus important. La concomitance de TCD et d’ATSM a aussi des effets sur les résultats après les traitements. Même si les troubles se manifestent et se terminent avec une gravité accrue dans ce sous-groupe, de l’admission au suivi, celui-ci rapportait les plus importantes baisses dans plusieurs comportements à risque, dans la consommation de drogues, dans les troubles émotifs, dans les activités illégales et dans le coût pour la société.Discussion : Les répercussions de ces résultats sont discutées et des stratégies potentielles sont suggérées pour améliorer l’efficacité des traitements et les services de soutien au rétablissement pour ces jeunes.Objective: To examine the relationship between co-occurring substance use disorders (SUDs) and other psychiatric disorders (OPD) and a wide range of human immunodeficiency virus (HIV) risk behaviors.Method: The data are from 17,141 youth aged 12–25 entering 148 adolescent and young adult treatment programs in the United States who were interviewed at intake and at one or more quarterly follow-up visits for 12 months using the Global Appraisal of Individual Needs (GAIN). Of the participants, 90% were adolescents (ages 12–17), 10% transitional-aged youth (ages 18–25), 72% male, 39% White, 16% African American, 26% Hispanic, 3% another race and 16% multi-racial. Approximately 61% of self-reports met past-year criteria for both SUD and OPD, 18% for SUD only and 10% for OPD only. Transitional-aged youth were similar in demographic and clinical characteristics, though a higher percentage (25%) reported SUD only.Results: For both age groups, individuals with co-occurring SUD and OPD were consistently the most likely to report past-year needle use; needle sharing; unprotected sex; multiple sexual partners; sex trading; high-risk sex partners; a history of physical, emotional, and sexual victimization; self-mutilation; suicidal or homicidal thoughts; illegal activity; and violence towards others. Transitional-aged youth also had the highest rates of emergency room visits and cost to society. Co-occurring SUD and OPD also impacts post-treatment outcomes; while frequently starting and ending with greater severity, this group still had the largest reductions in several risk behaviors, substance use, emotional problems, illegal activity, and costs to society from intake to follow-up.Discussion: The implications of these findings are discussed, along with possible strategies to improve the effectiveness of treatment and recovery support services for these youth.Objetivo: examinar la relación entre la concomitancia de los problemas relacionados con el consumo de drogas y otros problemas de salud mental con una amplia gama de comportamientos de riesgo para el virus de la inmunodeficiencia humana (VIH).Método: los datos se han extraído de un estudio llevado a cabo con 17 141 jóvenes de 12 a 25  años que iniciaban uno de los 148 programas de tratamiento para adolescentes y jóvenes adultos en Estados Unidos. Se administró a los jóvenes la Evaluación global de necesidades individuales (cuestionario GAIN) en el momento de su ingreso en el programa y por lo menos en una visita de seguimiento trimestral durante un período de 12 meses. Entre los participantes, el 90% eran adolescentes (de 12 a 17 años)y 10% estaban en etapa de transición (entre 18 y 25 años). El 72% eran de sexo masculino, 39% eran de origen caucásico, 16% de origen afroamericano, 26% de origen latinoamericano, 39% de otro grupo étnico y 16% eran pluriétnicos. Alrededor del 61% de las autoevaluaciones alcanzaban el criterio de clasificación de problemas relacionados con el consumo de drogas (PCD) y de otros problemas de salud mental (OPSM) durante al año precedente. El 18% alcanzaban el criterio de PCD solamente y el 10% el criterio de OPSM solamente durante el año anterior. Las características demográficas y clínicas de los jóvenes en etapa de transición eran similares, aunque había un más alto porcentaje de jóvenes (25%) que declararon tener un PCD solamente.Resultados: en los dos grupos de edad, las personas que tenían un PCD y OPSM concomitantes eran invariablemente los más susceptibles de declarar los comportamientos siguientes durante el último año : utilizar jeringas, compartir jeringas, tener relaciones sexuales no protegidas, compañeros/as sexuales múltiples, intercambio de favores sexuales; compañeros/as sexuales de alto riesgo, historia de victimización física, emocional y sexual; automutilación; ideas suicidas; ideas de asesinato; actividades ilegales y violencia contra los otros. Los jóvenes en etapa de transición presentaban también el porcentaje más alto de visitas a los servicios de emergencia hospitalaria y representan un costo más importante para la sociedad. La concomitancia de PCD y OPSM tiene también efectos sobre los resultados de los tratamientos. Aun si los problemas se manifiestan y se terminan con una gravedad más importante en este subgrupo, de la admisión al seguimiento, dicho subgrupo presenta las más importantes disminuciones en numerosos comportamientos de riesgo, en el consumo de drogas, en los problemas emocionales, en las actividades ilegales y en el costo para la sociedad.Discusión: se analizan las repercusiones de estos resultados y se sugieren estrategias que podrían mejorar la eficacia de los tratamientos y los servicios de apoyo al restablecimiento para estos jóvenes

Electronic Device Use: A Review of the Literature on Addictive Behaviors

This project aimed to determine if excessive device use while driving is the result of an addiction, why this behavior persists, and what countermeasures to consider. This Traffic Tech briefly summarizes it. Reviewers consulted academic, government, and private-sector material from several disciplines including human factors, traffic safety, psychology, and demography. More than 270 sources were reviewed with 155 critically reviewed using a structured document summary template. Reviewers found that electronic device use did not qualify for the formal definition of addiction described in DSM-5 since device users are not proven to demonstrate every aspect of addiction. However, excessive device use can mimic aspects of addiction since dependent users report a craving for their phone, they rely on mobile phones to relieve distress, and their emotions are highly influenced by their phones. Reviewers find that problematic device use is more likely to persist among certain demographics and personality types, including young people, less wealthy people, people with low self-esteem, and people with higher levels of anxiety, impulsivity, extraversion, and sensation-seeking