Saúde da mulher. Salud de la mujer

#Una nueva clase de #antibióticos podría ser eficaz en el tratamiento contra la #gonorrea (Antimicrob Agents Chemother)

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La amenaza inminente de enfermedades infecciosas resistentes a los antibióticos no tratables es un problema mundial.

Investigadores del Imperial College London y de la London School of Hygiene & Tropical Medicine (Reino Unido) han descubierto una nueva clase de antibióticos que, probados en laboratorio, se cree que podrían ser eficaces en el tratamiento contra la gonorrea.

En concreto, los investigadores, cuyo trabajo ha sido publicado en “Antimicrobial Agents and Chemotherapy”, probaron 149 muestras de la bacteria ‘N. gonorrhoeae’ de pacientes hospitalizados con infecciones en la garganta, la uretra, el cuello uterino y el recto. De esta forma, encontraron que, a dosis muy bajas (0,125 mg/l), el antibiótico closthioamide era eficaz en 146 de 149 muestras tomadas de los pacientes.

“La amenaza inminente de enfermedades infecciosas resistentes a los antibióticos no tratables, incluida la gonorrea, es un problema mundial, para el que necesitamos urgentemente nuevos antibióticos”, ha recordado el autor principal del Departamento Imperial de Ciencias de la Vida, John Heap.

Asimismo, la autora principal de la London School of Hygiene & Tropical Medicine, Victoria Miari, ha añadido que, con ninguna vacuna eficaz disponible, los nuevos antibióticos son “urgentemente” necesarios para hacer frente a esta infección que, sin tratamiento, puede tener consecuencias muy graves.

Aunque todavía no se ha probado en animales y seres humanos, los investigadores dicen que el antibiótico podría ser un nuevo paso en la lucha contra la enfermedad. Ahora, van a continuar el estudio en el laboratorio para evaluar aún más la seguridad y la eficacia del antibiótico.

#Tras una #reducción de estómago puede ser recomendable someterse a #cirugía estética

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Una vez transcurridos doce meses desde la intervención o después de haber logrado el peso deseado y ser capaz de mantenerlo.

La cirugía bariátrica abarca reducciones de estómago, balón gástrico o balón ajustable y, ante la cantidad de personas que son obesas en el mundo, esta parece “imponerse” para erradicar esta enfermedad, una intervención en la que puede ser recomendable someterse a una cirugía estética posterior en función del consejo del especialista, según el cirujano estético, Jordi Mir.

Estas alternativas para adelgazar se entienden como intervenciones quirúrgicas que no pueden contemplarse como un tratamiento individual, sino como parte fundamental de un proceso global, que contempla un seguimiento completo del paciente. “Por eso, se abarca no solo el pre y post operatorio, sino, por supuesto, la posterior re-educación alimenticia, el diseño de un plan de ejercicio personalizado y, por último, pero no menos importante, una propuesta estética si el paciente así lo desea”, ha concretado el experto.

En este sentido, el retoque estético se recomienda una vez transcurridos los doce meses desde la intervención o después de haber logrado el peso deseado y ser capaz de mantenerlo, teniendo en cuenta que “lo mejor” es tomarse el tiempo necesario para adelgazar, si se exceptúan los casos en los que los indicadores de salud son “tan malos” que se necesita una pérdida de peso “urgentísima”.

Así, tras una reducción de estómago u operación similar, las zonas más intervenidas en cirugía estética son el abdomen y la zona baja de la espalda, la cara interna de los muslos y la de los brazos. Además, “este tipo de intervenciones pueden generar un pérdida de los tejidos blandos faciales, con descolgamiento de los tercios medio e inferior”, ha explicado el Dr. Mir.

“Por lo tanto, se solicitan abdominoplastias, ‘lifting’ de brazos y muslos y ‘body lift’, un tratamiento completo de cirugía de contorno corporal destinada a la reducción de los excesos sobrantes de piel y a recuperar el tono y elasticidad de la misma”, ha añadido.

El especialista ha subrayado que el grado de satisfacción después de estas intervenciones, según su experiencia, es “altísimo”, tanto en cirugía como en medicina estética. Sin embargo, ha lamentado que sean pocos los centros públicos que reconocen la importancia de su contribución asociados a la cirugía bariátrica.

#Cesarean Complications Lower With #Poliglecaprone 25 Suture (II)

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When the researchers looked at the wound complication rate by actual suture received, the rate of wound complications was also lower in the poliglecaprone 25 suture group (8.3%) compared with the polyglactin 910 counterpart (13.8%), for a 40% reduction in the relative risk of developing a complication during the first 30 days postdelivery.

In this analysis, however, the difference between the two suture groups was no longer statistically significant (P = .05).

Lack of Braiding

Poliglecaprone 25 is a monofilament suture that is absorbed within 91 to 119 days postoperatively, the authors explain. The polyglactin 910 in turn is a braided suture which is absorbed much more quickly within 56 to 70 days after surgery. “Cesarean incision closure with poliglecaprone 25 suture is associated with a significantly decreased rate of wound complications when compared with polyglactin 910 suture,” they write. “We speculate that this significant difference was the result of the lack of braiding in the poliglecaprone 25 suture that allowed for increased resistance to infection.”

In an accompanying audio clip, Nancy Chescheir, MD, editor-in-chief of Obstetrics & Gynecology, observed that most wound complications show up early, not 56 to 119 days after the wound has been closed.

“When I was a medical student, surgeons made a big deal out of time to dissolution of absorbable sutures,” she said. “So the fact that the length of time it takes the suture to dissolve in the wound isn’t the issue here, there’s something else going on earlier in the process of wound healing that is making the difference here,” she noted. “Some of the simple things make the best science,” She added.

The authors have disclosed no relevant financial relationships.

Obstet Gynecol. 2017;130:521-526. Abstract


#Cesarean Complications Lower With #Poliglecaprone 25 Suture (I)

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In women who undergo elective cesarean delivery, wound complications are lower in Pfannenstiel incisions closed with poliglecaprone 25 suture compared with in those who receive polyglactin 910 suture, a randomized comparative trial found.

“The incidence of wound complications after cesarean delivery comparing suture and staple skin closure has been extensively studied with suture being superior,” Arin Buresch, MD, from Kaiser Permanente San Diego, California, and colleagues report.

“[And now we’ve] found that for skin closure after delivery, poliglecaprone 25 suture was associated with a 40% reduction in the rate of wound complications when compared with polyglactin 910 suture,” they add.

The researchers present their findings in an article published online August 4 and in the September issue of Obstetrics & Gynecology.

The primary outcome was a composite outcome of a wound complication during the first 30 days postoperatively that included one or more of the following: a wound separation of 1 cm or more in length, hematoma, seroma, or surgical site infection.

In an intention-to-treat analysis, 8.8% of women who underwent subcuticular closure of their Pfannenstiel skin incision with the 3-0 poliglecaprone 25 (Monocryl) suture experienced the primary outcome compared with 14.4% of women in whom a 4-0 polyglactin 910 (Vicryl) suture was used (relative risk, 0.61; 95% confidence interval, 0.37 – 0.99; P = .04).

Surgeons would need to treat 18 women with the poliglecaprone 25 suture to prevent one composite wound complication after caesarean section.

The study was carried out in labor and delivery units at two medical centers in California. During slightly more than 1 year, 275 women were randomly assigned to undergo cesarean delivery in which the poliglecaprone 25 suture was used, and another 275 women were randomly assigned to the same procedure with skin closure using the polyglactin 910 suture.

The final analysis included 263 women in the poliglecaprone 25 suture group, 231 of whom underwent the procedure with the assigned suture, and 257 women in the polyglactin 910 group, 209 of whom received the assigned suture.

Groups were well balanced in terms of demographics, comorbidities, and perioperative characteristics, the researchers note. The investigators calculated outcomes by intention-to-treat analysis as well as by the actual suture received. In the intent-to-treat analysis, rates of specific wound complications were usually higher in the polyglactin 910 suture group as well.

Table. Wound Complication Rates: Intent-to-Treat Analysis

Complication Poliglecaprone 25 Polyglactin 901
Surgical site infection 6.1% 9.7%
Hematoma 0.4% 1.2%
Seroma 0.8% 0.4%
Separation 2.7% 5.1%

#Cardiovascular fat volume linked to #body fat distribution in #women

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White women with higher BMIs and black women with more abdominal fat are more likely to accumulate fat around the heart.

Findings from a new study could help provide clues as to a female patient’s likelihood of having greater cardiovascular fat volumes.

The study, published in Menopause, included 524 women enrolled in the US Study of Women’s Health Across the Nation (SWAN). The women were in varying stages of menopause, averaged 51 years old and were not on hormone replacement therapy.

The study found that every 1 standard deviation increase in BMI was associated with 66.7 per cent greater paracardial fat (PAT) volume in white women compared with 42.4 per cent greater PAT volume in black women, whereas every 1 standard deviation increase in visceral fat (VAT) was associated with 32.3 per cent greater epicardial fat (EAT) volume in black women compared with 25.3 per cent greater EAT volume in white women.

Black women had significantly less cardiovascular fat volumes compared with white women independent of adiposity measures.
The authors said the findings provide another tool to help evaluate patients and get a better sense of their cardiovascular disease risk. “It also may lead to suggestions for lifestyle modifications to help patients lessen that risk,” said senior author, Samar El Khoudary.

#Techniques for preventing hypotension during #spinal anaesthesia for #caesarean section

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Authors

  • Cheryl Chooi,

  • Julia J Cox,

  • Richard S Lumb,

  • Philippa Middleton,

  • Mark Chemali,

  • Richard S Emmett,

  • Scott W Simmons,

  • Allan M Cyna

  • First published: 4 August 2017
  • Editorial Group: Cochrane Pregnancy and Childbirth Group
  • DOI: 10.1002/14651858.CD002251.pub3
  • Cited by (CrossRef): 0 articlesCheck for updates

Abstract

Background

Maternal hypotension is the most frequent complication of spinal anaesthesia for caesarean section. It can be associated with nausea or vomiting and may pose serious risks to the mother (unconsciousness, pulmonary aspiration) and baby (hypoxia, acidosis, neurological injury).

Objectives

To assess the effects of prophylactic interventions for hypotension following spinal anaesthesia for caesarean section.

Search methods

We searched Cochrane Pregnancy and Childbirth’s Trials Register (9 August 2016) and reference lists of retrieved studies.

Selection criteria

Randomised controlled trials, including full texts and abstracts, comparing interventions to prevent hypotension with placebo or alternative treatment in women having spinal anaesthesia for caesarean section. We excluded studies if hypotension was not an outcome measure.

Data collection and analysis

Two review authors independently assessed study quality and extracted data from eligible studies. We report ‘Summary of findings’ tables using GRADE.

Main results

We included 126 studies involving 9565 participants. Interventions were to prevent maternal hypotension following spinal anaesthesia only, and we excluded any interventions considered active treatment. All the included studies reported the review’s primary outcome. Across 49 comparisons, we identified three intervention groups: intravenous fluids, pharmacological interventions, and physical interventions. Authors reported no serious adverse effects with any of the interventions investigated. Most trials reported hypotension requiring intervention and Apgar score of less than 8 at five minutes as the only outcomes. None of the trials included in the comparisons we describe reported admission to neonatal intensive care unit.

Crystalloid versus control (no fluids)

Fewer women experienced hypotension in the crystalloid group compared with no fluids (average risk ratio (RR) 0.84, 95% confidence interval (CI) 0.72 to 0.98; 370 women; 5 studies; low-quality evidence). There was no clear difference between groups in numbers of women with nausea and vomiting (average RR 0.19, 95% CI 0.01 to 3.91; 1 study; 69 women; very low-quality evidence). No baby had an Apgar score of less than 8 at five minutes in either group (60 babies, low-quality evidence).

Colloid versus crystalloid

Fewer women experienced hypotension in the colloid group compared with the crystalloid group (average RR 0.68, 95% CI 0.58 to 0.80; 2105 women; 28 studies; very low-quality evidence). There were no clear differences between groups for maternal hypertension requiring intervention (average RR 0.64, 95% CI 0.09 to 4.46, 3 studies, 327 women;very low-quality evidence), maternal bradycardia requiring intervention (average RR 0.99, 95% CI 0.55 to 1.79, 6 studies, 509 women; very low-quality evidence), nausea and/or vomiting (average RR 0.83, 95% CI 0.61 to 1.13, 15 studies, 1154 women, I² = 37%; very low-quality evidence), neonatal acidosis (average RR 0.83, 95% CI 0.15 to 4.52, 6 studies, 678 babies; very low-quality evidence), or Apgar score of less than 8 at five minutes (average RR 0.24, 95% CI 0.03 to 2.05, 11 studies, 826 babies; very low-quality evidence).

Ephedrine versus phenylephrine

There were no clear differences between ephedrine and phenylephrine groups for preventing maternal hypotension (average RR 0.92, 95% CI 0.71 to 1.18; 401 women; 8 studies; very low-quality evidence) or hypertension (average RR 1.72, 95% CI 0.71 to 4.16, 2 studies, 118 women, low-quality evidence). Rates of bradycardia were lower in the ephedrine group (average RR 0.37, 95% CI 0.21 to 0.64, 5 studies, 304 women, low-quality evidence). There was no clear difference in the number of women with nausea and/or vomiting (average RR 0.76, 95% CI 0.39 to 1.49, 4 studies, 204 women, I² = 37%, very low-quality evidence), or babies with neonatal acidosis (average RR 0.89, 95% CI 0.07 to 12.00, 3 studies, 175 babies, low-quality evidence). No baby had an Apgar score of less than 8 at five minutes in either group (321 babies; low-quality evidence).

Ondansetron versus control

Ondansetron administration was more effective than control (placebo saline) for preventing hypotension requiring treatment (average RR 0.67, 95% CI 0.54 to 0.83; 740 women, 8 studies, low-quality evidence), bradycardia requiring treatment (average RR 0.49, 95% CI 0.28 to 0.87; 740 women, 8 studies, low-quality evidence), and nausea and/or vomiting (average RR 0.35, 95% CI 0.24 to 0.51; 653 women, 7 studies, low-quality evidence). There was no clear difference between the groups in rates of neonatal acidosis (average RR 0.48, 95% CI 0.05 to 5.09; 134 babies; 2 studies, low-quality evidence) or Apgar scores of less than 8 at five minutes (284 babies, low-quality evidence).

Lower limb compression versus control

Lower limb compression was more effective than control for preventing hypotension (average RR 0.61, 95% CI 0.47 to 0.78, 11 studies, 705 women, I² = 65%, very low-quality evidence). There was no clear difference between the groups in rates of bradycardia (RR 0.63, 95% CI 0.11 to 3.56, 1 study, 74 women, very low-quality evidence) or nausea and/or vomiting (average RR 0.42 , 95% CI 0.14 to 1.27, 4 studies, 276 women, I² = 32%, very-low quality evidence). No baby had an Apgar score of less than 8 at five minutes in either group (130 babies, very low-quality evidence).

Walking versus lying

There was no clear difference between the groups for women with hypotension requiring treatment (RR 0.71, 95% CI 0.41 to 1.21, 1 study, 37 women, very low-quality evidence).

Many included studies reported little to no information that would allow an assessment of their risk of bias, limiting our ability to draw meaningful conclusions. GRADE assessments of the quality of evidence ranged from very low to low. We downgraded evidence for limitations in study design, imprecision, and indirectness; most studies assessed only women scheduled for elective caesarean sections.

External validity also needs consideration. Readers should question the use of colloids in this context given the serious potential side effects such as allergy and renal failure associated with their administration.

Authors’ conclusions

While interventions such as crystalloids, colloids, ephedrine, phenylephrine, ondansetron, or lower leg compression can reduce the incidence of hypotension, none have been shown to eliminate the need to treat maternal hypotension in some women. We cannot draw any conclusions regarding rare adverse effects associated with use of the interventions (for example colloids) due to the relatively small numbers of women studied.

Plain language summary

Techniques for preventing a decrease in blood pressure during spinal anaesthesia for caesarean section

What is the issue?

Spinal anaesthesia is a commonly used technique for caesarean birth as the mother is able to be awake for the birth and usually remains comfortable afterwards. In addition, the technique avoids the risks of general anaesthesia. The most common adverse effect of spinal anaesthesia is a fall in blood pressure (hypotension).

This study reviews the evidence for preventing hypotension following spinal anaesthesia for caesarean birth.

Why is this important?

Hypotension following spinal anaesthesia for caesarean birth occurs frequently. When it occurs, the mother may feel faint or nauseous and may vomit. If her blood pressure falls excessively, the mother runs serious risks (such as loss of consciousness), as does the baby (such as lack of oxygen and brain damage). Hypotension may be prevented by administering intravenous fluids, giving medications (such as ephedrine, phenylephrine, and ondansetron), by leg compression, or by the mother either lying down or walking around before the spinal anaesthesia.

What evidence did we find?

We searched the evidence in August 2016 and found a total of 126 studies involving 9565 women. Included studies investigated 49 different comparisons, which we split into three groups: intravenous fluid therapy, medications, and physical methods. Here we describe the results of the six main comparisons (crystalloid versus control; colloid versus crystalloid; ephedrine versus phenylephrine; ondansetron versus control; leg compression versus control; walking versus lying).

Fluid therapy (crystalloid versus control; colloid versus crystalloid)

It is uncertain whether crystalloids prevent hypotension because the quality of the evidence is very low. Giving colloids instead of crystalloids may mean that fewer women have low blood pressure after having spinal anaesthesia.

We cannot be certain due to the very low quality evidence whether crystalloid or colloid are better at preventing maternal low heart rate (bradycardia), high blood pressure, nausea and vomiting, neonatal acidosis, or low Apgar scores. Whether women received crystalloids or no fluids did not affect the number of women who experienced nausea and/or vomiting.

Medications (ephedrine versus phenylephrine; ondansetron versus control)

Lower rates of bradycardia occurred in women receiving ephedrine versus phenylephrine, and with ondansetron versus no ondansetron, but the evidence is low quality. Ondansetron may prevent low blood pressure and nausea/vomiting but made little or no difference to neonatal acidosis or Apgar scores. There was little difference between ephedrine and phenylephrine for low or high blood pressure, nausea and vomiting, neonatal acidosis, or Apgar scores. We cannot be certain of these results due to the low or very low quality of the evidence.

Physical methods (leg compression versus control; walking versus lying)

It is uncertain whether leg compression reduces the number of women with hypotension compared with no leg compression because the quality of evidence is very low. Similarly, we cannot be certain whether leg compression made any difference to women experiencing bradycardia or nausea and vomiting, or to babies’ Apgar scores. It is also uncertain whether walking or lying down before the spinal anaesthesia reduces low blood pressure.

What does this mean?

We found that no single method completely prevents hypotension in women receiving spinal anaesthesia during caesarean birth. Administering intravenous fluids or certain medications, and compressing the legs with bandages, stockings, or inflatable devices may reduce the incidence of hypotension. However, we found the quality of the evidence to be low or very low, so there is still a need for large, high-quality studies using these clinically relevant interventions, either alone or in combination.

Future research in this setting could focus on combinations of these effective strategies or on new innovative strategies.

Not a single country is meeting # breastfeeding standards

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Only 40 per cent of children younger than six months are breastfed exclusively.

The Global Breastfeeding Collective, a new initiative to increase global breastfeeding rates, is calling on countries to implement the Ten Steps to Successful Breastfeeding in maternity facilities, including providing breast milk for sick and vulnerable newborns. Among other measures, it wants to see links between health facilities and communities strengthened, and improved access to skilled breastfeeding counselling as part of comprehensive breastfeeding policies and programmes in health facilities.

The recommendations follow the publication of a new report by Global Breastfeeding Collective members UNICEF and the World Health Organization this week, which found that not a single country in the world fully meets recommended standards for breastfeeding. The Global Breastfeeding Scorecard found only 40 per cent of children younger than six months are breastfed exclusively and only 23 countries have exclusive breastfeeding rates above 60 per cent.

The report was released to coincide with World Breastfeeding Week (August 1 to 7), alongside a new analysis  which demonstrates that an annual investment of only €4 per newborn would be required to increase the global rate of exclusive breastfeeding among children under six months to 50 per cent by 2025.