Archive for month: November, 2024

New research reveals many prenatal vitamins don’t contain enough of the nutrients that are essential for a healthy pregnancy, while others contain harmful levels of toxic metals.

The study published in The American Journal of Clinical Nutrition checked the amounts of choline and iodine in nonprescription and prescription prenatal vitamins. The research also checked for toxic metals like arsenic, lead and cadmium.

“During pregnancy, many women rely on prenatal vitamins and minerals to support their health and their baby’s development. Among the most crucial nutrients for fetal development are choline and iodine. However, some prenatal vitamins may not contain the exact amounts listed on the label and some may not contain any choline or iodine,” said the study’s first author Laura Borgelt, PharmD, MBA, professor at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences at CU Anschutz. “Our study aims to help women better understand the nutrient content in prenatal supplements, empowering them to make more informed choices and select the best options for their health and their baby’s well-being.”

The researchers tested a sample of 47 different prenatal vitamins (32 nonprescription and 15 prescription products) bought from online and local stores where people commonly shop. They then measured the actual amounts of choline and iodine in their lab versus what was on the label and also checked for arsenic, lead and cadmium. They compared their findings with official safety standards within 20% of the claimed amount.

The Food and Nutrition Board of the Institute of Medicine recommends dietary reference intakes for choline at 450 mg/day during pregnancy and 550 mg/day during lactation, with a tolerable upper limit of 3,500 mg/day. For iodine, the recommended dietary reference intake for females aged 19 and older is 150 mcg/day, increasing to 220 mcg/day during pregnancy and 290 mcg/day during lactation. The tolerable upper limit for iodine is 1,100 mcg/day.

Additionally, the United States Pharmacopeia has established purity standards for pharmaceuticals, including limits for harmful substances: arsenic (2.5 mcg per oral daily dose), cadmium (0.5 mcg per oral daily dose) and lead (0.5 mcg per oral daily dose).

The researchers found most prenatal vitamins do not list choline, and many of those that do, don’t contain the correct amount. Only 12 listed the choline content, which is about 26% and only five products (42%) had the right amount of choline as promised on the label.

When checking for iodine, they found most prenatal vitamins contain less than advertised, and very few provided the correct amount, with 53% of products listing iodine content, but only four (16%) products contained the claimed amount of iodine on the label.

They also found some products contained levels of heavy metals that were higher than expected. Specifically, seven products had too much arsenic, two had too much lead and 13 had too much cadmium, all above the purity limits set by the U.S. Pharmacopeia. Exposure to these heavy metals in pregnancy has been associated with adverse birth outcomes.

“We’re one of the first studies to measure the actual amounts of choline and iodine in a large sample of prenatal supplements. The presence of contaminants, especially cadmium, was also concerning. Our findings highlight a significant gap between what’s listed on the labels and what’s actually in the products, underscoring the urgent need for stronger regulatory oversight in this area,” Borgelt adds.

The authors mention that although there’s a need for more oversight in ensuring supplements have enough of each ingredient, prenatal supplements are still important to take during pregnancy. They recommend double-checking ingredients or working with a doctor or healthcare professional to choose the prenatal supplement.

Reference:

Laura M. Borgelt, Michael Armstrong, Stephen Brindley, Jared M. Brown, Nichole Reisdorph, Carol A. Stamm. Content of Selected Nutrients and Potential Contaminants in Prenatal Multivitamins and Minerals: an Observational Study. The American Journal of Clinical Nutrition, 2024; DOI: 10.1016/j.ajcnut.2024.11.014.

A recent retrospective study published in The Laryngoscope journal found the patients with single intraoperative steroid injection experience shorter surgery-free interval in idiopathic subglottic stenosis (iSGS). This research was conducted over an 11-year period from January 1, 2012 to December 1, 2023 to evaluate how different treatment strategies impacted the surgery-free interval (SFI), which represents the duration between surgical interventions.

The study encompassed a total of 305 procedures involving 104 patients to compare the outcomes among different treatment protocols. The patients were divided into 4 main groups based on their treatment as endoscopic dilation (ED) alone, ED with a single intraoperative corticosteroid injection, ED followed by a single in-office intralesional steroid injection (ILSI), and ED with serial in-office steroid injection (SILSI) procedures postoperatively.

• Endoscopic Dilation Alone: This group consisted of 55 procedures and had a median SFI of 658 days (IQR: 595 days). It emerged as the treatment associated with the longest interval between surgeries.
• ED with Single Intraoperative Steroid Injection: This was the largest subgroup, with 102 procedures recorded. The median SFI here dropped notably to 395 days (IQR: 296 days) by indicating a statistically significant decrease in the surgery-free period when compared to ED alone (p = 0.001).
• ED Followed by Single Postoperative ILSI: This approach was applied in 27 procedures and resulted in a median SFI of 533 days (IQR: 351 days). Although longer than the intraoperative-only group, it still did not surpass the outcomes of ED alone.
• ED with Serial SILSI Procedures: This method comprised of 15 procedures and showed a median SFI of 585 days (IQR: 338 days). Despite the introduction of regular, serial steroid injections, the increase in SFI was not significantly different from the ED-alone group.

The study highlighted a critical insight, where the use of a single intraoperative steroid injection correlated with a significantly reduced SFI when compared to using endoscopic dilation alone. This outcome points to the potential limitations of single-use steroid injections in extending the time between surgical interventions.

The patients managed with ED followed by serial SILSI procedures did not experience significant improvements in SFI when compared to the ones who only underwent dilation. This finding suggests that while serial steroid injections might offer some benefits, their impact may not be substantial enough to alter the surgical interval significantly within this patient population. Overall, the outcomes of this research reinforces the importance of treatment selection in managing iSGS by emphasizing that while steroids are a common adjunct to surgical procedures, their long-term efficacy in extending SFI warrants further exploration.

Reference:

Ramazani, F., Bosch, J. D., & Randall, D. R. (2024). Comparing Intraoperative and In‐Office Steroid Injections for Management of Subglottic Stenosis. In The Laryngoscope. Wiley. https://doi.org/10.1002/lary.31903

Bone mineral density declines more rapidly in adults with cystic fibrosis, according to a study published in the Journal of Bone and Mineral Research.

A new study published in the Journal of American Medical Association showed that fewer than 90 total standardized doses (TSDs) of opioids were not substantially linked to an increased risk of dementia. With over 10 million new cases reported each year and a fast rising incidence worldwide, dementia is becoming a more serious public health concern. Between 2000 and 2019, the usage of opioids quadrupled more than usual throughout the globe. Although opioids have been investigated as a possible risk factor for dementia, there is little data linking long-term noncancer opioid usage and the sole use of mild opioids to an increased risk of dementia. Thus, Nelsan Pourhadi and colleagues carried out this investigation to evaluate the relationship between the risk of age-related all-cause dementia and the cumulative noncancer usage of opioids.

In this population-based cohort nested case-control research, 1,872 854 people without a history of dementia, opioid addiction, cancer, or opioid use in terminal illness were included. Every person with dementia during follow-up was incidence-density matched to 5 controls who did not have dementia. The period of statistical analysis was August 2023 to March 2024. The total amount of opioid exposure was calculated using filled prescriptions from 1995 to 2020. The main findings of this study were adjusted incidence rate ratios (IRRs) for the relationships between opioids and dementia, which were obtained using conditional logistic regression.

A total of 93,638 of the 1,872 854 participants in the trial who had no prior history of dementia, opioid addiction, cancer, or opioid use in terminal illness acquired all-cause dementia during follow-up. These participants were matched to 468 190 control participants. The risk of dementia was not consistently linked to the use of opioids up to 90 total standardized doses. Increased IRRs of dementia occurring before the age of 90 years were found for opioid exposure above 90 TSDs. These IRRs ranged from 1.29 for 91 to 200 TSDs to 1.59 for higher than 500 TSDs for age-band 60 to 69 years at dementia diagnoses.

For the age group of 70 to 79 years, the corresponding IRRs were 1.16 to 1.49, and for the age group of 80 to 89 years, they were 1.08 to 1.21. The sensitivity tests confirmed correlations between mild opioids and persistent non-cancer pain. Overall, while some models revealed a statistically significant positive correlation with 31 to 90 TSDs, this investigation found that cumulative opioid exposure below 90 TSDs was not consistently linked to an elevated risk of dementia.

Reference:

Pourhadi, N., Janbek, J., Gasse, C., Laursen, T. M., Waldemar, G., & Jensen-Dahm, C. (2024). Opioids and Dementia in the Danish Population. In JAMA Network Open (Vol. 7, Issue 11, p. e2445904). American Medical Association (AMA). https://doi.org/10.1001/jamanetworkopen.2024.45904

Advances in cardiac imaging techniques and risk categorization have led to improvements in diagnosis, initial treatment and long-term management of patients with Kawasaki Disease, according to a new scientific statement published today in the American Heart Association’s flagship, peer-reviewed journal Circulation.

The new statement, “Update on Diagnosis and Management of Kawasaki Disease,” summarizes the data published since the 2017 American Heart Association Scientific Statement on Kawasaki Disease related to diagnostic criteria, risk scores and treatment options for children and adults with this condition.

Statement highlights include:

Kawasaki Disease is a rare but serious illness primarily affecting children younger than five years old. The disease can cause inflamed blood vessels throughout the body, and it is the leading cause of acquired (not congenital) heart disease in children throughout the developed world.

Although the cause of Kawasaki Disease is still unknown, however, there is a strong suspicion that the cause is infectious but no single infectious agent has been implicated. Health care professionals diagnose Kawasaki Disease based on a set of well-established symptoms, including prolonged fever, rash, reddened eyes and swelling of the hands and feet. Without timely treatment, one in four children can develop coronary artery dilation and/or coronary artery aneurysms.

Health care professionals use coronary artery Z-scores, a measurement that compares the coronary artery diameter of a child with Kawasaki Disease to the expected diameter of coronary arteries in healthy children of similar age, sex and body size to evaluate coronary abnormalities and classify risk. Children with Z-scores greater than 2.5 are at increased risk for developing coronary artery aneurysms. Although a Z-score alone should not determine the damage to coronary arteries, the statement highlights the need for consistent Z-score equation over time to ensure a patient’s risk classification does not change.

Early identification of children with Kawasaki Disease at risk of developing coronary artery aneurysms remains a challenge in a multi­ethnic population and it is critical to diagnose Kawasaki Disease early for optimal management. A new risk scoring system specific to children in North America combines factors like age younger than six months, Asian race, elevated coronary artery Z-scores of at least 2 and higher C-reactive protein levels (a substance in the blood that is elevated when there’s inflammation in the body). These advancements help clinicians identify high-risk patients who might require more intensive initial treatment to potentially reduce coronary artery complications​.

The statement suggests echocardiograms at regular time intervals, with a higher frequency in patients with coronary artery Z-scores greater than 2.5, to track the progression of any coronary artery abnormalities during hospitalization or after discharge. Echocardiographic, or heart ultrasound, techniques have improved since 2017 to better detect coronary artery dilation or aneurysms, which can help patients avoid more serious and/or long-term heart problems.

Intravenous immunoglobulin (IVIG), a mixture of antibodies and proteins to help fight infections, remains the standard of care for patients with Kawasaki Disease. Studies have shown, however, that dosing adjustments based on lean body mass in patients with obesity can help reduce the risks of complications.

The statement reevaluates the use of aspirin during the acute phase of Kawasaki Disease. Recent studies have shown using low- or medium-dose aspirin may be just as effective as high-dose aspirin. Ongoing trials are comparing different doses to confirm these results.

Recent studies have found adding other therapies, such as corticosteroids or infliximab, can help children with Kawasaki Disease who are at high risk for IVIG resistance. These new options may be effective in preventing coronary artery complications and offer health care professionals more options in managing treatment-resistant cases.

For children with Kawasaki Disease who have larger coronary aneurysms, blood-thinning medications like aspirin (typically 81 mg daily) combined with anticoagulants, such as warfarin or low molecular weight heparin, may help prevent dangerous blood clots. Recent evidence indicates that using direct oral anticoagulants in the treatment of patients with large coronary artery aneurysms may be more effective and safer, require less monitoring and have fewer side effects, however, further research is needed to confirm these findings.

The outbreak of COVID-19 saw an increase in a related condition called Multisystem Inflammatory Syndrome in Children (MIS-C). MIS-C became a diagnostic challenge since many symptoms including fever, rash and heart-related issues, overlap with symptoms of Kawasaki Disease. New data have helped differentiate the two conditions by identifying additional symptoms of MIS-C that include gastrointestinal issues, a low number of platelets that could cause bruising or bleeding, and a lower than normal number of white blood cells. In contrast, coronary artery involvement remains a hallmark of Kawasaki Disease, helping health care professionals make more accurate diagnoses. Machine learning algorithms have also been developed that may help clinicians distinguish between Kawasaki Disease and MIS-C.

All medical centers with patients with Kawasaki Disease and giant coronary artery aneurysms need to have a multidisciplinary heart team and a protocol in place to address major adverse cardiac events.

This updated scientific statement highlights the need for a formal transition program to ensure continuity of care for adolescents and adults with a history of Kawasaki Disease. Patients with giant aneurysms remain at high risk for heart attack and require lifelong monitoring and care. Further research is needed to optimize the timing and methods used to monitor long-term heart health in patients with the disease.

Individuals with Kawasaki Disease who plan on becoming pregnant are at high risk for adverse cardiac events and require care from obstetricians who have knowledge of Kawasaki Disease in tandem with consultations with a cardiologist.

This scientific statement was prepared by the volunteer writing group on behalf of the American Heart Association’s Rheumatic Feber, Endocarditis, and Kawasaki Disease Committee of the Council on Lifelong Congenital Heart Disease and Heart Health in the Youn; the Council on Cardiovascular and Stroke Nursing; the Council on Cardiovascular Radiology and Intervention; and the Council on Clinical Cardiology. American Heart Association scientific statements promote greater awareness about cardiovascular diseases and stroke issues and help facilitate informed health care decisions. Scientific statements outline what is currently known about a topic and what areas need additional research. While scientific statements inform the development of guidelines, they do not make treatment recommendations. American Heart Association guidelines provide the Association’s official clinical practice recommendations.

Statement writing group authors and their disclosures are listed in the manuscript.

The Association receives funding primarily from individuals. Foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific Association programs and events. The Association has strict policies to prevent these relationships from influencing the science content. Revenues from pharmaceutical and biotech companies, device manufacturers and health insurance providers, and the Association’s overall financial information are available here.