Women's perspectives about cannabis use during pregnancy and the postpartum period: An integrative review.

Cannabis is the most commonly used illicit drug among general and pregnant populations. Despite recommendations to abstain from cannabis use, its use is increasing during the perinatal period. In this integrative review, we aim to understand women's perspectives about the health aspects of perinatal cannabis use. The following databases were searched: MEDLINE, PsycInfo, EMBASE, and CINAHL. We included quantitative and qualitative studies with a primary focus on perinatal cannabis use. The methodological quality of the included studies was appraised using appropriate checklists. Extracted data were integrated into a single data matrix and iteratively compared across studies to summarize and synthesize the data. Full text of 33 citations was retrieved and reviewed of which 6 studies met the inclusion criteria. Women who continued to use cannabis during pregnancy often perceived no general or pregnancy-specific risk compared to nonusers. The uncertainty regarding adverse perinatal consequences, its perceived therapeutic effects, and lower costs of cannabis compared to that of cigarettes contributed to cannabis use. A lack of communication with health care providers regarding the health aspects of cannabis was evident. Women perceived this lack of counseling as an indication that adverse outcomes associated with cannabis use are not significant. Women's perceptions of health risks associated with cannabis use are important factors in the decision-making process regarding use or cessation, particularly as legal concerns are fading away. A discussion about health concerns surrounding cannabis use may influence women's perceptions of risk and help them to make informed choices.

Does Molimina Indicate Ovulation? Prospective Data in a Hormonally Documented Single-Cycle in Spontaneously Menstruating Women.

Approximately 33% of normal-length (21⁻35 days) cycles have subclinical ovulatory disturbances and lack sufficient progesterone, although their normal length ensures enough estrogen. Subclinical ovulatory disturbances are related to significant premenopausal spine bone loss (-0.86%/year). Molimina, non-distressing premenstrual experiences, may detect ovulation within normal-length cycles. This prospective study assessed the relationship between molimina and ovulation. After 1-cycle of daily diary and first morning urine collections, women answered the Molimina Question (MQ): "Can you tell by the way you feel that your period is coming?" and were invited to share (a) predictive premenstrual experience(s). A 3-fold increase in follicular-luteal pregnanediol levels confirmed ovulation. In 610 spontaneously menstruating women (not on hormonal contraception, mean age 31.5 ± 5.3, menarche age 12.7 ± 1.5, cycle length [CL] 29 days, MQ positive in 89%), reported premenstrual experiences which included negative moods (62%), cramps (48%), bloating (39%), and front (26%) or axillary (25%) breast tenderness. Of 432 women with pregnanediol-documented cycles, 398 (92%) were ovulatory (CL: 29 ± 5) and 34 (8%) had ovulatory disturbances (CL: 32 ± 14). Women with/without ovulatory cycles were similar in parity, body mass index, smoking, dietary restraint and the MQ; ovulatory-disturbed cycles were longer. Molimina did not confirm ovulation. A non-invasive, inexpensive ovulation indicator is needed to prevent osteoporosis.

Leukocyte telomere length in HIV-infected and HIV-exposed uninfected children: shorter telomeres with uncontrolled HIV viremia.

OBJECTIVES: Nucleoside reverse transcriptase inhibitors (NRTIs) used in HIV antiretroviral therapy can inhibit human telomerase reverse transcriptase. We therefore investigated whether in utero or childhood exposure to NRTIs affects leukocyte telomere length (LTL), a marker of cellular aging. METHODS: In this cross-sectional CARMA cohort study, we investigated factors associated with LTL in HIV-1-infected (HIV(+)) children (n = 94), HIV-1-exposed uninfected (HEU) children who were exposed to antiretroviral therapy (ART) perinatally (n = 177), and HIV-unexposed uninfected (HIV(-)) control children (n = 104) aged 0-19 years. Univariate followed by multivariate linear regression models were used to examine relationships of explanatory variables with LTL for: a) all subjects, b) HIV(+)/HEU children only, and c) HIV(+) children only. RESULTS: After adjusting for age and gender, there was no difference in LTL between the 3 groups, when considering children of all ages together. In multivariate models, older age and male gender were associated with shorter LTL. For the HIV(+) group alone, having a detectable HIV viral load was also strongly associated with shorter LTL (p = 0.007). CONCLUSIONS: In this large study, group rates of LTL attrition were similar for HIV(+), HEU and HIV(-) children. No associations between children's LTL and their perinatal ART exposure or HIV status were seen in linear regression models. However, the association between having a detectable HIV viral load and shorter LTL suggests that uncontrolled HIV viremia rather than duration of ART exposure may be associated with acceleration of blood telomere attrition.

Homelessness as viewed by incarcerated women: participatory research.

PURPOSE: The purpose of this paper is to describe the development, by incarcerated women who were members of a prison participatory health research team, of a survey tool regarding homelessness and housing, the survey findings and recommendations for policy. DESIGN/METHODOLOGY/APPROACH: A survey was developed by incarcerated women in a minimum/medium security women's prison in Canada. Associations were examined between socio-demographic factors and reports of difficulty finding housing upon release, homelessness contributing to a return to crime, and a desire for relocation to another city upon release. Open-ended questions were examined to look for recurrent themes and to illuminate the survey findings. FINDINGS: In total, 83 women completed the survey, a 72 per cent response rate. Of the 71 who were previously incarcerated, 56 per cent stated that homelessness contributed to their return to crime. Finding housing upon release was a problem for 63 per cent and 34 per cent desired relocation to another city upon release. Women indicated that a successful housing plan should incorporate flexible progressive staged housing. RESEARCH LIMITATIONS/IMPLICATIONS: The present study focuses only on incarcerated women but could be expanded in future to include men. PRACTICAL IMPLICATIONS: Incarcerated women used the findings to create a housing proposal for prison leavers and created a resource database of the limited housing resources for women prison leavers. SOCIAL IMPLICATIONS: Lack of suitable housing is a major factor leading to recidivism. This study highlights the reality of the cycle of homelessness, poverty, crime for survival, street-life leading to drug use and barriers to health, education and employment that incarcerated women face. ORIGINALITY/VALUE: Housing is a recognized basic determinant of health. No previous studies have used participatory research to address homelessness in a prison population.

Maternal and foetal outcomes among pregnant women hospitalised due to interpersonal violence: a population based study in Western Australia, 2002-2008.

BACKGROUND: Interpersonal violence is responsible for more ill-health and premature death in women under the age of 45 than other preventable health conditions, but findings concerning the effects of violence during pregnancy on both maternal and foetal health have been inconsistent. METHODS: A retrospective population-based cohort study was undertaken using linked data from the Hospital Morbidity Data Collection and the Western Australian Midwives' Notification System from 2002 to 2008. The aim was to determine the association between exposure to interpersonal violence during pregnancy and adverse maternal and foetal health outcomes at the population level. RESULTS: A total of 468 pregnant women were hospitalised for an incident of interpersonal violence during the study period, and 3,744 randomly selected pregnant women were included as the comparison group. The majority of violent events were perpetrated by the pregnant women's partner or spouse. Pregnant Indigenous women were over-represented accounting for 67% of all hospitalisations due to violence and their risk of experiencing adverse maternal outcomes was significantly increased compared to non-Indigenous women (adjusted odds ratio 1.53, 95% CI 1.21 to 1.95, p = 0.01). Pregnant women hospitalised for an incident of interpersonal violence sustained almost double the risk for adverse maternal complications than the non-exposed group (95% CI 1.34 to 2.18, p < 0.001). The overall risk for adverse foetal complications for pregnant women exposed to violence was increased two-fold (95% CI 1.50 to 2.76, p < 0.001). CONCLUSIONS: The risk of adverse health outcomes for both the mother and the baby increases if a pregnant woman is hospitalised for an incident of interpersonal violence during pregnancy.

Analysis of recurrent events: a systematic review of randomised controlled trials of interventions to prevent falls.

RATIONALE: there are several well-developed statistical methods for analysing recurrent events. Although there are guidelines for reporting the design and methodology of randomised controlled trials (RCTs), analysis guidelines do not exist to guide the analysis for RCTs with recurrent events. Application of statistical methods that do not account for recurrent events may provide erroneous results when used to test the efficacy of an intervention. It is unknown what proportion of RCTs of falls prevention studies have utilised statistical methods that incorporate recurrent events. METHODS: we conducted a systematic review of RCTs of interventions to prevent falls in community-dwelling older persons. We searched Medline from 1994 to November 2006. We determined the proportion of studies that reported using three statistical methods appropriate for the analysis of recurrent events (negative binomial regression, Andersen-Gill extension of the Cox model and the WLW marginal model). RESULTS: fewer than one-third of 83 papers that reported falls as an outcome utilised any appropriate statistical method (negative binomial regression, Andersen-Gill extension of the Cox model and Cox marginal model) to analyse recurrent events and fewer than 15% utilised graphical methods to represent falls data. CONCLUSION: RCTs that have a recurrent event end-point should include an analysis appropriate for recurrent event data such as negative binomial regression, Andersen-Gill extension of the Cox model and/or the WLW marginal model. We recommend that researchers and clinicians seek consultation with a statistician with expertise in recurrent event methodology.

Time-activity patterns of pregnant women and changes during the course of pregnancy.

Numerous studies suggest that in utero exposures to environmental contaminants are associated with fetal development, congenital anomalies, learning difficulties or other health impacts later in life. Although location and time-activity data have been used to model exposure to specific contaminants in epidemiological studies, little information is available about time-activity patterns of pregnant women. We measured changes in location-based activity patterns over the course of pregnancy (48-h periods, during two or three trimesters) using a self-reported time-activity log among a nonrandom sample of pregnant women (n=62). We assessed the influence of demographics and personal factors on changes in activity over pregnancy using mixed effects regression models. Increasing weeks of pregnancy was a significant predictor for increased time spent at home (1 h/day increase for each trimester of pregnancy), after adjusting for income (2.6 more h/day at home in lowest income group), work status (3.5 more h/day at home for nonworkers) and other children in the family (1.5 more h/day at home with other children). No other measured activities (time outdoors, time in transit modalities or time in other indoor locations) were related to weeks of pregnancy. As our results indicate that pregnant women tend to spend more time at home during the latter stages of pregnancy, future exposure and epidemiological research should consider the potential increase in home-based exposures (i.e., indoor air pollution or chemicals in the home) late in pregnancy, and increased confidence in exposure proxies based on home locations or characteristics during the same period.

Utility of the mean cumulative function in the analysis of fall events.

BACKGROUND: Falls are the most common cause of injury among elderly people; half of those people fall recurrently. The objective of these simulation studies was to describe the Mean Cumulative Function (MCF) and to evaluate the utility of the MCF in detecting differences between groups experiencing different patterns of event intensities. METHODS: We specified 250 participants per group with a maximum follow-up time of 365 days. A participant could experience 0, 1, 2, 3, or 4 falls. In the baseline experiment, Groups A and B had an average intensity of 60 and 90 days to the first fall event. These event intensities remained constant for events 2-4. Group C represents a short term "strong" initial impact of the intervention modeled for falls 1 and 2, with an average intensity of one fall per 117 days; however, the intervention wanes to "moderate" for falls 3 and 4 with an average intensity of one fall per 90 days. Group D represents a long-term "strong" impact of the intervention modeled by an average intensity of one fall per 117 days for all subsequent events. RESULTS: The MCF was able to detect differences between groups that had varying intensities of subsequent falls. In Group A, all participants experienced at least one fall, whereas Groups B, C, and D had 4, 9, and 15 participants, respectively, who did not experience any falls. The proportion of participants who had 4 falls declined from 84% to 40% in Groups A and D, respectively. When Group A was compared to Group D, the MCF difference detected the prevention of, on average, one fall per person within 175 days. Discussion. A novel instrument for this field of clinical research--the MCF--allows investigators to compare the average number of falls per participant when the intervention reduces the intensity of subsequent falls.

Emergency department fall-related presentations do not trigger fall risk assessment: a gap in care of high-risk outpatient fallers.

We wanted to determine whether women aged 70 years and older, who presented to the emergency department (ED) with a fall and injury, received guideline care within 18 months of presentation. Women aged 70 years and older who presented to the ED with a fall were recorded prospectively from August 1, 2001 to May 1, 2002 (n=226). Structured telephone interviews were performed 18 months after the ED fall to obtain details of patient management (n=63). The most frequently reported referral was to the family physician (32%) and to physiotherapy (24%). We concluded that most older women who presented to the ED with a fall did not appear to be receiving current guideline care. We propose that future research use a prospective study design to assess whether or not guideline care is being delivered by a variety of health care providers after the patients leave the ED.

Wristwatch-distal radial fracture as a marker for osteoporosis investigation: a controlled trial of patient education and a physician alerting system.

This article reports a controlled trial to investigate the effectiveness of patient education and a physician alerting system in altering secondary osteoporosis prevention after a low-trauma (fragility) wrist fracture and to record the current rate of osteoporosis investigation following such fractures. Fifty-one women and men aged 50 years or older with a low-trauma wrist fracture were identified (41 women and 10 men; mean age [95% CI], 71.51 [67.31-74.81]). The intervention group received a four-part intervention aimed at both the patient and the family physician in addition to the usual care for the fracture. The control group only received usual care for the fracture. Data were collected for both groups at six weeks and six months. Results indicate that 92% of the intervention subjects were investigated for osteoporosis, compared with the usual-care group, in which only 23% were investigated. Early osteoporosis intervention has the potential to limit disease impact, and hand therapists can play a key role in early identification of osteoporosis.

Resistance and agility training reduce fall risk in women aged 75 to 85 with low bone mass: a 6-month randomized, controlled trial.

OBJECTIVES: To compare the effectiveness of group resistance and agility-training programs in reducing fall risk in community-dwelling older women with low bone mass. DESIGN: A randomized, controlled, single-blind 25-week prospective study with assessments at baseline, midpoint, and trial completion. SETTING: Community center. PARTICIPANTS: Community-dwelling women aged 75 to 85 with low bone mass. INTERVENTION: Participants were randomly assigned to one of three groups: resistance training (n=32), agility training (n=34), and stretching (sham) exercises (n=32). The exercise classes for each study arm were held twice weekly. MEASUREMENTS: The primary outcome measure was fall risk (derived from weighted scores from tests of postural sway, reaction time, strength, proprioception, and vision), as measured using a Physiological Profile Assessment (PPA). Secondary outcome measures were ankle dorsiflexion strength, foot reaction time, and Community Balance and Mobility Scale score. RESULTS: Attendance at the exercise sessions for all three groups was excellent: resistance training (85.4%), agility training (87.3%), and stretching program (78.8%). At the end of the trial, PPA fall-risk scores were reduced by 57.3% and 47.5% in the resistance and agility-training groups, respectively, but by only 20.2% in the stretching group. In the resistance and agility groups, the reduction in fall risk was mediated primarily by improved postural stability, where sway was reduced by 30.6% and 29.2%, respectively. There were no significant differences between the groups for the secondary outcomes measures. Within the resistance-training group, reductions in sway were significantly associated with improved strength, as assessed using increased squat load used in the exercise sessions. CONCLUSION: These findings support the implementation of community-based resistance and agility-training programs to reduce fall risk in older women with low bone mass. Such programs may have particular public health benefits because it has been shown that this group is at increased risk of falling and sustaining fall-related fractures.

Community-based exercise program reduces risk factors for falls in 65- to 75-year-old women with osteoporosis: randomized controlled trial.

BACKGROUND: Exercise programs improve balance, strength and agility in elderly people and thus may prevent falls. However, specific exercise programs that might be widely used in the community and that might be "prescribed" by physicians, especially for patients with osteoporosis, have not been evaluated. We conducted a randomized controlled trial of such a program designed specifically for women with osteoporosis. METHODS: We identified women 65 to 75 years of age in whom osteoporosis had been diagnosed by dual-energy X-ray absorptiometry in our hospital between 1996 and 2000 and who were not engaged in regular weekly programs of moderate or hard exercise. Women who agreed to participate were randomly assigned to participate in a twice-weekly exercise class or to not participate in the class. We measured baseline data and, 20 weeks later, changes in static balance (by dynamic posturography), dynamic balance (by a timed figure-eight run) and knee extension strength (by dynamometry). RESULTS: Of 93 women who began the trial, 80 completed it. Before adjustment for covariates, the intervention group tended to have greater, although nonsignificant, improvements in static balance (mean difference 4.8%, 95% confidence interval [CI] -1.3% to 11.0%), dynamic balance (mean difference 3.3%, 95% CI -1.7% to 8.4%) and knee extension strength (mean difference 7.8%, 95% CI -5.4% to 21.0%). Mean crude changes in the static balance score were -0.85 (95% CI -2.91 to 1.21) for the control group and 1.40 (95% CI -0.66 to 3.46) for the intervention group. Mean crude changes in figure-eight velocity (dynamic balance) were 0.08 (95% CI 0.02 to 0.14) m/s for the control group and 0.14 (95% CI 0.08 to 0.20) m/s for the intervention group. For knee extension strength, mean changes were -0.58 (95% CI -3.02 to 1.81) kg/m for the control group and 1.03 (95% CI -1.31 to 3.34) kg/m for the intervention group. After adjustment for age, physical activity and years of estrogen use, the improvement in dynamic balance was 4.9% greater for the intervention group than for the control group (p = 0.044). After adjustment for physical activity, cognitive status and number of fractures ever, the improvement in knee extension strength was 12.8% greater for the intervention group than for the control group (p = 0.047). The intervention group also had a 6.3% greater improvement in static balance after adjustment for rheumatoid arthritis and osteoarthritis, but this difference was not significant (p = 0.06). INTERPRETATION: Relative to controls, participants in the exercise program experienced improvements in dynamic balance and strength, both important determinants of risk for falls, particularly in older women with osteoporosis.

Knee extension strength is a significant determinant of static and dynamic balance as well as quality of life in older community-dwelling women with osteoporosis.

BACKGROUND: Determinants of balance have not been well studied in women with osteoporosis yet falls are the major cause of fracture in this population. OBJECTIVE: To describe the associations among knee extension strength, medication history, medical history, physical activity and both static and dynamic balance in women diagnosed with osteoporosis. METHODS: We assessed health history, current medication and quality of life by questionnaire in 97 community-dwelling women with osteoporosis. Static balance was measured by computerized dynamic posturography (Equitest), dynamic balance by timed figure-eight run, and knee extension strength by dynamometry. RESULTS: The 97 participants (mean (SD) age 69 (3.2) years) had a mean lumbar spine BMD of T = -3.3 (0.7) and total hip BMD of -2.9 (0.4). In stepwise linear regression, the significant determinants of static balance that explained 18% of total variance were knee extension strength (10%, p < 0.001), age (5%, p < 0.01) and tobacco use (3%, p < 0.05). The significant predictors of dynamic balance were knee extension strength (26%, p < 0.001), medications (6%, p < 0.05), age (4%, p < 0.05), height (4%, p < 0.001), as well as years of estrogen use (2%), tobacco use (2%) and weight (2%) (all p < 0.05). Knee extension strength was also associated with quality of life (r(2) = 0.12, p < 0.001). Based on these models, a 1 kg/cm ( approximately 3%) increase in mean knee extension strength was associated with 1.2, 2.4 and 3.4% greater static balance, dynamic balance and quality of life, respectively. CONCLUSIONS: Knee extension strength is a significant determinant of performance on static and dynamic balance tests in 65- to 75-year-old women with osteoporosis. In this cross-sectional study, knee extension strength explained a greater proportion of the variance in balance tests than did age. Investigation into the effect of intervention to improve knee extension strength in older women with osteoporosis is warranted.