NSIDRC Journal Article Alert — December 14, 2007

Prepared by the National Sudden Infant Death Resource Center at Georgetown University.

This journal article alert provides selected items added to the National Library of Medicine’s PubMed database in the last week.

Past issues of NSIDRC journal alerts are available at http://www.sidscenter.org.
Availability of full-text journal articles is often limited to subscribers or through inter-library loan. Please see your local library for copies of these articles, or view PubMed's How to Get the Journal Article for more details.

Sudden Infant Death

1: Porzionato A, Macchi V, Parenti A, Matturri L, De Caro R.
Peripheral chemoreceptors: postnatal development and cytochemical findings in Sudden Infant Death Syndrome.
Histol Histopathol. 2008 Mar;23(3):351-65.

Section of Anatomy, Department of Human Anatomy and Physiology, University of Padova, Italy.

The aim of the present study is to give a review of the postnatal development of peripheral chemoreceptors - carotid body, paraganglia, and pulmonary neuroendocrine cells (PNEC) - with implications in Sudden Infant Death Syndrome (SIDS). In the postnatal period, the hypoxic chemosensitivity of the carotid body gradually develops. Changes include proliferation of type I and II cells, increased numbers of dense core vesicles and K+ channels, and modifications of neurotransmitter/neuromodulator and receptor expression. Chromaffin paraganglia show increased expression of nitric oxide synthase and neuropeptides, and increased innervation. Innervation of PNEC develops fully only in the first postnatal period, after which their density falls. The neuropeptides produced by PNEC also changes, with increased expression of calcitonin gene-related peptide and neuropeptide YY and reduced expression of calcitonin and gastrin-releasing peptide. Most of the findings in the carotid body of SIDS victims, i.e., decrease in type I cells and dense cytoplasmic granules, and increase in progenitor cells, indicates immaturity of the carotid body, which may play a role in SIDS in the form of underlying biologic vulnerability. Aorticopulmonary paraganglia hyperplasia and increase of PNEC are also found in SIDS, and may be epiphenomena of alterations of the respiratory function with a pathogenetical role in SIDS. A comprehensive view of the pathogenesis of SIDS should also arise from the integration of peripheral chemoreceptors findings with neuro- and cardiopathologic ones.

Bereavement

1: Kissane D, Lichtenthal WG, Zaider T.
Family care before and after bereavement.
Omega (Westport). 2007-2008;56(1):21-32

Department of Psychiatry & Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA. kissaned@mskcc.org

Distress reverberates throughout the family during palliative care and bereavement, inviting consideration of a family-centered model of care. Targeting families thought to be "at risk" has merit. The Family Focused Grief Therapy model was tested in a randomized controlled trial of 81 families (353 individuals) and bereavement outcome is reported here for treatment completers compared to controls. There were no significant baseline differences between treatment completers and non-completers. Significant reduction in distress occurred at 13 months post death for the families completing treatment, with further improvements for the 10% of individuals most distressed at baseline. A preventive model of family-centered care applied to those at greatest risk is meritorious and in keeping with the aspirations of Cicely Saunders for improving the quality of hospice care.

2: Hastings SO, Musambira GW, Hoover JD.
Community as a key to healing after the death of a child.
Commun Med. 2007;4(2):153-63

Nicholson School of Communication, University of Central Florida, Orlando, FL 32816, USA. hastings@pegasus.cc.ucf.edu

Communication is believed to hold a central role in recreating an individual's sense of meaning and well-being after a loss. Narrative theory in particular points to ways that people create meaning and connection with others. Literature on bereavement suggests that the formation of connections with others, or building community, comprises an important part of the healing process. For this study, the content of bulletin board postings commemorating deceased children was studied quantitatively and qualitatively. Data were examined to learn how contributors used the Web site to connect with others who shared experience of losing a child, engage in meaningful shared activities, and create community. Findings from the data analysis suggest that the Web site contributors are able to discuss topics that might be restricted in other communication scenes. The discussion of these topics allows them to serve as 'witnesses' to truths learned as a result of the loss of a child and enables the participants to keep the memory of the child alive. By participating in this scene of meaning negotiation, we argue that the participants actively construct a counterplot to societal narrative expectations for bereavement that facilitates the creation of some positive meanings.

3: Stroebe M, Schut H, Stroebe W..
Health outcomes of bereavement.
Lancet. 2007 Dec 8;370(9603):1960-73

Research Institute for Psychology and Health, Utrecht University, Utrecht, Netherlands. M.S.Stroebe@UU.NL

In this Review, we look at the relation between bereavement and physical and mental health. Although grief is not a disease and most people adjust without professional psychological intervention, bereavement is associated with excess risk of mortality, particularly in the early weeks and months after loss. It is related to decrements in physical health, indicated by presence of symptoms and illnesses, and use of medical services. Furthermore, bereaved individuals report diverse psychological reactions. For a few people, mental disorders or complications in the grieving process ensue. We summarise research on risk factors that increase vulnerability of some bereaved individuals. Diverse factors (circumstances of death, intrapersonal and interpersonal variables, ways of coping) are likely to co-determine excesses in ill-health. We also assess the effectiveness of psychological intervention programmes. Intervention should be targeted at high-risk people and those with complicated grief or bereavement-related depression and stress disorders.

Miscarriage/Stillbirth/Prenatal Issues

1: Fucic A, Merlo DF, Ceppi M, Lucas JN.
Spontaneous abortions in female populations occupationally exposed to ionizing radiation.
Int Arch Occup Environ Health. 2007 Dec 4 [Epub ahead of print]

Institute for Medical Research and Occupational Health, 10000, Zagreb, Ksaverska c 2, Croatia, afucic@imi.hr.

OBJECTIVE: Exposure to radioisotopes of metals and halogen elements occurring in medical practice may cause spontaneous abortions. The potential role of occupational exposure to X-rays and internal radioisotopes on pregnancy outcome in childbearing age women employed in hospital departments were analyzed in order to estimate miscarriage risk. METHODS: Over a period of 16 years, the occurrence of miscarriages in 61 women exposed to radioisotopes was compared to that reported in 170 X-ray exposed women. Chromosomal aberrations (CA) were measured in both radiation-exposed groups and in 53 non-exposed women. RESULTS: Women exposed to radioisotopes experienced at least a threefold higher rate of spontaneous abortions than those exposed to X-ray (OR = 3.68, 95% CI = 1.39-9.74, P < 0.01). Although X-ray and radioisotopes exposed women had significantly higher levels of chromosome type frequency (0.51 ± 0.82, and 0.63 ± 0.99, respectively) than referents (0.17 ± 0.34), there was no clear difference between radiation-exposed women. CONCLUSIONS: For exposure levels within standard recommended guidelines, radioisotopes are far more likely to play a role in the occurrence of spontaneous abortions than X-rays. Such biological effect is not detectable by deviations in CA frequency.

2: Dudley DJ.
Diabetic-associated stillbirth: incidence, pathophysiology, and prevention.
Clin Perinatol. 2007 Dec;34(4):611-26.

Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.

All forms of diabetes during pregnancy are associated with an increased risk for stillbirth, defined as fetal death at greater than 20 weeks. The incidence of stillbirth in women who have diabetes has decreased dramatically with improved diabetes care. Diabetic-associated stillbirth is associated with hyperglycemia, resulting in fetal anaerobic metabolism with hypoxia and acidosis. Prevention of stillbirth in women who have diabetes hinges on intensive multidisciplinary prenatal care with control of blood sugars and appropriate fetal surveillance.

3: Strasburger JF, Cheulkar B, Wichman HJ.
Perinatal arrhythmias: diagnosis and management.
Clin Perinatol. 2007 Dec;34(4):627-52.

Children's Hospital of Wisconsin - Fox Valley, 200 Theda Clark Medical Plaza, Suite 480, Neenah, WI 54956-2884, USA.

The final common pathway to death in all of us is an arrhythmia, yet we still know far too little about the contribution of conduction abnormalities and arrhythmias to the compromised states of the human fetus. At no other time in the human life cycle is the human being at more risk of unexplained and unexpected death than during the prenatal period. The risk of sudden death from 20-40 weeks gestation is 6-12 deaths/1000 fetuses/year. This is equal to, and in some ethnic groups HIGHER than, the risk of death in the adult population with known coronary artery disease over the same time frame (6-12 deaths/1000 patients/year). Because only a small percentage of the United States population is pregnant each year, because fetal demise is not often acknowledged through public displays such as funerals, and finally because fetal death is culturally accepted to a much greater extent than it should be, this critically important area of women's healthcare has not had the technological advances that have been seen in adult cardiac intensive care and other areas of medicine. Fetal cardiac deaths may be preventable and the diseases that lead to these deaths are often treatable, especially if the sophistication of our modern ICU's could somehow be translated to the prenatal monitoring arena. This review article will outline recent advances in evaluating fetal electrophysiology, helping the perinatologist to better understand the nuances of fetal arrhythmias.

4: Bauersachs RM, Dudenhausen J, Faridi A, Fischer T, Fung S, Geisen U, Harenberg J, Herchenhan E, Keller F, Kemkes-Matthes B, Schinzel H, Spannagl M, Thaler CJ; for the EThIG Investigators.
Risk stratification and heparin prophylaxis to prevent venous thromboembolism in pregnant women.
Thromb Haemost. 2007 Dec;98(6):1237-45.

Medical Department IV - Vascular Medicine, Klinikum Darmstadt, Grafenstrasse 9, 64283 Darmstadt, Germany. E-mail: Rupert.Bauersachs@Klinikum-Darmstadt.de.

Women with a history of venous thromboembolism (VTE), thrombophilia or both may be at increased risk of thrombosis during pregnancy, but the optimal management strategy is not well defined in clinical guidelines because of limited trial data. A strategy of risk assessment and heparin prophylaxis was evaluated in pregnant women at increased risk of VTE. In a prospective trial (Efficacy of Thromboprophylaxis as an Intervention during. Gravidity [EThIG]), 810 pregnant women were assigned to one of three management strategies according to pre-defined risk factors related to history of VTE and thrombophilic profile. Low-risk women (group I), received 50-100 IU dalteparin/kg body weight/day for 14 days postpartum, or earlier when additional risk factors occurred. Women at high (group II) or very high risk (group III) received dalteparin from enrolment until six weeks postpartum (50-100 IU and 100-200 IU/kg/day, respectively). Objectively confirmed, symptomatic VTE occurred in 5/810 women (0.6%; 95% confidence interval [CI], 0.2 to 1.5%) (group I, 0 of 225; II, 3/469; III, 2/116). The rate of serious bleeding was 3.0% (95 % CI, 1.9 to 4.4%); 1.1% (95 % CI, 0.5 to 2.2%) was possibly dalteparin-related. There was no evidence of heparin-induced thrombocytopenia, one case of osteoporosis, and rates of miscarriage and stillbirth were similar to previous, retrospective studies. Risk-stratified heparin prophylaxis was associated with a low incidence of symptomaticVTE and few clinically important adverse events. Antepartum heparin prophylaxis is, therefore, warranted in pregnant women with idiopathic thrombosis or symptomatic thrombophilia.

5: Metwally M, Ong KJ, Ledger WL, Li TC
Does high body mass index increase the risk of miscarriage after spontaneous and assisted conception? A meta-analysis of the evidence.
.Fertil Steril. 2007 Dec 6 [Epub ahead of print]

Academic Unit of Reproductive and Developmental Medicine, The University of Sheffield and Sheffield Teaching Hospitals, The Jessop Wing, Sheffield, United Kingdom.

OBJECTIVE: To investigate the association between obesity and miscarriage. DESIGN: Meta-analysis. SETTING: The Academic Unit of Reproductive and Developmental Medicine, The University of Sheffield, United Kingdom. PATIENT(S): Obese and overweight patients who had miscarriage after spontaneous or assisted conception, compared with patients with a normal body mass index. INTERVENTION(S): A systematic review was conducted for all relevant articles in MEDLINE from 1964 to September 2006 and in EMBASE from 1974 to September 2006, using a combination of the following search terms: obesity/obes */obes$/BMI, miscarriage/abortion/pregnancy, IVF, clomifene/clomiphene, gonadotrophins/gonadotrop */gonadotrop$. MAIN OUTCOME MEASURE(S): Pregnancy loss at <20 weeks of gestation. RESULT(S): Sixteen studies were included in the meta-analysis. Patients with a body mass index of >/=25 kg/m(2) had significantly higher odds of miscarriage, regardless of the method of conception (odds ratio, 1.67; 95% confidence interval, 1.25-2.25). Subgroup analysis from a limited number of studies suggested that this group of women may also have significantly higher odds of miscarriage after oocyte donation (odds ratio, 1.52; 95% confidence interval, 1.10-2.09) and ovulation induction (odds ratio, 5.11; 95% confidence interval, 1.76-14.83). There was no evidence for increased odds of miscarriage after IVF-intracytoplasmic sperm injection. CONCLUSION(S): There is evidence that obesity may increase the general risk of miscarriage. However, there is insufficient evidence to describe the effect of obesity on miscarriage in specific groups such as those conceiving after assisted conception.

6: Fawzy M, Shokeir T, El-Tatongy M, Warda O, El-Refaiey AA, Mosbah A
Treatment options and pregnancy outcome in women with idiopathic recurrent miscarriage: a randomized placebo-controlled study.
Arch Gynecol Obstet. 2007 Dec 11 [Epub ahead of print]

Department of Obstetrics and Gynecology, Mansoura Faculty of Medicine, Mansoura University Hospital, Mansoura, Egypt, mmfawzy@hotmail.com.

OBJECTIVE: To compare the use of enoxaparin alone with combination therapy of prednisone, aspirin and progesterone in the treatment of women with idiopathic recurrent miscarriage (IRM) in terms of live births and pregnancy outcome. METHODS: A prospective, randomized, single-blinded, placebo-controlled trial was conducted at a tertiary referral obstetric hospital. The participants were 170 women with a diagnosis of IRM. Women were recruited after full investigative screening. Women with >/=3 fetal losses and after exclusion of all known causes of recurrent miscarriage were randomly allocated to receive either enoxaparin alone, combination treatment consisting of prednisone, aspirin, and progesterone or placebo. Rates of live births, antenatal complications, delivery and neonatal outcomes were recorded prospectively. Data were statistically analyzed as appropriate. RESULTS: Ten patients were dropped out after random assignment. Eighty-one percent of the enoxaparin (46/57) group and 85% of the combination-treated group (45/53) were delivered of live infants compared to 48% (24/50) of the placebo (P < 0.05). Women who were treated with combination therapy had a 4.2% higher live birth rate than enoxaparin group. This difference was not significant. Miscarriage rates were significantly lower in the treated groups compared with placebo (P < 0.05). There were no significant differences in late obstetric complications or neonatal mortality between groups. CONCLUSIONS: A combination treatment consisting of high-dose, low-duration prednisone, progesterone and aspirin might be an effective treatment as enoxaparin alone. Both regimens were associated with a good pregnancy outcome.

Prepared by the
National Sudden Infant Death Resource Center
Georgetown University
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