Women's Clinical Preventive Services: Closing the Gaps and Implementing in Practice.

Evidence-based clinical preventive services have the potential to reduce morbidity and mortality and optimize health. The Affordable Care Act mandates coverage without cost-sharing for several clinical preventive services. The Women's Preventive Services Initiative (WPSI) has worked to and continues to identify gaps in recommended preventive services for women. The WPSI Well-Woman Chart and the accompanying Clinical Summary Tables can be used at the point of care to ensure women are offered and receive all the preventive services recommended for their age and circumstance.

Folic acid supplementation for the prevention of neural tube defects: an update of the evidence for the U.S. Preventive Services Task Force.

BACKGROUND: Neural tube defects (NTDs) are among the most common birth defects in the United States. In 1996, the U.S. Preventive Services Task Force (USPSTF) recommended that all women planning a pregnancy or capable of conception take a supplement containing folic acid to reduce the risk for NTDs. PURPOSE: To search for new evidence published since 1996 on the benefits and harms of folic acid supplementation for women of childbearing age to prevent neural tube defects in offspring, to inform an updated USPSTF recommendation. DATA SOURCES: MEDLINE and Cochrane Central Register of Controlled Trials searches from January 1995 through December 2008, recent systematic reviews, reference lists of retrieved articles, and expert suggestions. STUDY SELECTION: English-language randomized, controlled trials; cohort studies; case-control studies; systematic reviews; and meta-analyses were selected if they provided information on the benefits and harms of folic acid supplementation in women of childbearing age to reduce NTDs in offspring. DATA EXTRACTION: All studies were reviewed, abstracted, and rated for quality by using predefined USPSTF criteria. DATA SYNTHESIS: Four observational studies reported benefit of reduction of risk for NTDs associated with folic acid-containing supplements. Differences in study type and methods prevent the calculation of a summary of the reduction in risk. The one included study on harms reported that the association of twinning with folic acid intake disappeared after adjustment for in vitro fertilization and underreporting of folic acid intake. LIMITATIONS: The evidence on dose was limited. No evidence was found on the potential harm of masking vitamin B(12) deficiency in women of childbearing age. The search focused on the association of NTDs with supplementation only and therefore does not provide a comprehensive review of the effects of folic acid on all possible outcomes or of the effects of dietary intake of folic acid. CONCLUSION: New observational evidence supports previous evidence from a randomized, controlled trial that folic acid-containing supplements reduce the risk for NTD-affected pregnancies. The association of folic acid use with twin gestation may be confounded by fertility interventions.

Benefits and risks of oral diabetes agents compared with insulin in women with gestational diabetes: a systematic review.

OBJECTIVE: Little is known about the comparative risks and benefits of medical treatments for gestational diabetes mellitus (GDM). We conducted a systematic review of randomized controlled trials and observational studies of maternal and neonatal outcomes in women with GDM treated with oral diabetes agents compared with all types of insulin. DATA SOURCES: We searched four electronic databases from inception through January 2007. Terms for GDM, insulins, and oral hypoglycemic agents were used in the search. Two investigators independently reviewed titles and abstracts, performed data abstraction on full articles, and assessed study quality. METHOD OF STUDY SELECTION: Articles were excluded if they had no comparison group or did not use a standard diagnosis of GDM (3-hour, 100-g oral glucose tolerance test or 2-hour, 75-g oral glucose tolerance test). Nine studies met our inclusion criteria, four randomized controlled trials (n=1,229 participants) and five observational studies (n=831 participants). Data were abstracted on study characteristics, gestational age at treatment, medication dosage, and length of follow-up. Outcomes included glycemic control, infant birth weight, neonatal hypoglycemia, and congenital anomalies. TABULATION, INTEGRATION, AND RESULTS: Two trials compared insulin to glyburide; one trial compared insulin, glyburide, and acarbose; and one trial compared insulin to metformin. No significant differences were found in maternal glycemic control or cesarean delivery rates between the insulin and glyburide groups. A meta-analysis showed similar infant birth weights between women treated with glyburide and women treated with insulin (mean difference -93 g) (95% confidence interval -191 to 5 g). There was a higher proportion of infants with neonatal hypoglycemia in the insulin group (8.1%) compared with the metformin group (3.3%) (P=.008). The rate of congenital malformations did not differ between pregnancies treated with insulin and those treated with oral agents. Observational studies were limited by selection bias and confounding. CONCLUSION: No substantial maternal or neonatal outcome differences were found with the use of glyburide or metformin compared with use of insulin in women with GDM.

Active compared with expectant delivery management in women with gestational diabetes: a systematic review.

OBJECTIVE: We conducted a systematic review to estimate benefits and harms of the choice of timing of induction or elective cesarean delivery based on estimated fetal weight or gestational age in women with gestational diabetes mellitus (GDM). DATA SOURCES: An electronic literature search was performed using MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature, and The Cochrane Central Register of Controlled Trials from inception to January 2007. METHODS OF STUDY SELECTION: Two investigators independently reviewed titles and abstracts, assessed article quality, and abstracted data. Maternal outcomes included cesarean delivery and operative vaginal delivery. Neonatal outcomes included birth weight, macrosomia, large for gestational age, shoulder dystocia, birth trauma, neonatal intensive care admissions, and perinatal mortality. TABULATION, INTEGRATION, AND RESULTS: Five studies met our inclusion criteria: one randomized controlled trial (RCT) and four observational studies. The RCT (n=200) compared the effect of labor induction at term with expectant management. The proportion of newborns with birth weight greater than the 90th percentile was significantly greater in the expectant-management group (23% compared with 10% with active induction, P=.02); there were no significant differences in rates of cesarean delivery, shoulder dystocia, neonatal hypoglycemia, or perinatal deaths. The four observational studies suggest a potential reduction in macrosomia and shoulder dystocia with labor induction and cesarean delivery for estimated fetal weight indications, but there was insufficient evidence to assess other clinical outcomes. CONCLUSION: Active rather than expectant management of labor at term for women with GDM may reduce rates of macrosomia and related complications. Further RCTs and observational studies with a broader range of outcomes are needed for sufficient evidence to inform clinical practice.

Natural history of fetal position during pregnancy and risk of nonvertex delivery.

OBJECTIVE: To examine the natural history of fetal position throughout pregnancy and the likelihood for nonvertex delivery. METHODS: We examined fetal positions at 15-22 weeks, at 31-35 weeks, and at delivery using data from the Routine Antenatal Diagnostic Imaging with Ultrasound trial. Characteristics of women with nonvertex and vertex presentation at delivery were compared. Multivariable logistic regression analysis was performed to determine risk factors for nonvertex presentation at delivery, and odds ratios were calculated for those risk factors found to be statistically significantly associated with nonvertex presentation. RESULTS: Data for 7,045 women who underwent routine prenatal ultrasound examinations were analyzed. We found no association between nonvertex presentation at 15-22 and at 31-35 weeks of gestation. A nonvertex fetus at 35 weeks had a 45% chance of spontaneous version by delivery. Multivariable logistic regression analysis found that multiparous women had half of the risk of nonvertex presentation as nulliparous women. Smoking during pregnancy (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.10-1.96), low volume of amniotic fluid at 31-35 weeks (OR 3.74, 95% CI 1.85-7.53), and fundal position of the placenta at late ultrasound examination (OR 1.85, 95% CI 1.23-2.78) were all associated with significant increases in the risk of nonvertex position at delivery. CONCLUSION: Spontaneous version of a nonvertex fetus at 35 weeks of gestation is still likely.

Use of metformin in polycystic ovary syndrome: a meta-analysis.

OBJECTIVE: To update the state of evidence on the efficacy of metformin, used either alone or in combination with clomiphene citrate in women with polycystic ovary syndrome, by examining three outcomes: ovulation, pregnancy, and live birth. Sources of heterogeneity among the published randomized controlled trials are systematically assessed. DATA SOURCES: An electronic literature search was performed using MEDLINE, EMBASE, SCOPUS, CENTRAL, Cochrane, and U.S. Food and Drug Administration databases, restricted to studies conducted on humans and published in English. METHODS OF STUDY SELECTION: Of the 406 potentially relevant articles identified, 17 met criteria for inclusion in the meta-analysis, rendering a total sample of 1,639 women. Study quality was examined in terms of randomization scheme, masking process, adequacy of allocation concealment, statistical power, and loss to follow-up; publication bias was also assessed. Meta-analytic procedures were used to compare metformin with placebo, and metformin plus clomiphene with clomiphene alone, for all study outcomes. Exploratory analyses were conducted to assess differences in treatment effects between clomiphene-resistant and nonresistant patients, obese and nonobese patients, and trials with long and short durations of follow-up. TABULATION, INTEGRATION, AND RESULTS: Metformin improved the odds of ovulation in women with polycystic ovary syndrome when compared with placebo (odds ratio [OR] 2.94; 95% confidence interval [CI] 1.43-6.02; number-needed-to-treat 4.0) and appears more effective for non-clomiphene-resistant women. Metformin and clomiphene increased the likelihood of ovulation (OR 4.39; 95% CI 1.94-9.96; number-needed-to-treat 3.7) and pregnancy (OR 2.67; 95% CI 1.45-4.94; number-needed-to-treat 4.6) when compared with clomiphene alone, especially in clomiphene-resistant and obese women with polycystic ovary syndrome. These treatment effects were greater for trials with shorter follow-up. CONCLUSION: Using all available evidence, this meta-analysis suggests that metformin increases the likelihood of ovulation and, in combination with clomiphene, increases the odds of both ovulation and pregnancy in women with polycystic ovary syndrome.

Novel Influenza A (H1N1) outbreak at the U.S. Air Force Academy: epidemiology and viral shedding duration.

BACKGROUND: The U.S. Air Force Academy is an undergraduate institution that educates and trains cadets for military service. Following the arrival of 1376 basic cadet trainees in June 2009, surveillance revealed an increase in cadets presenting with respiratory illness. Specimens from ill cadets tested positive for novel influenza A (H1N1 [nH1N1])-specific ribonucleic acid (RNA) by real-time reverse transcriptase-polymerase chain reaction. PURPOSE: The outbreak epidemiology, control measures, and nH1N1 shedding duration are described. METHODS: Case patients were identified through retrospective and prospective surveillance. Symptoms, signs, and illness duration were documented. Nasal-wash specimens were tested for nH1N1-specific RNA. Serial samples from a subset of 53 patients were assessed for presence of viable virus by viral culture. RESULTS: A total of 134 confirmed and 33 suspected cases of nH1N1 infection were identified with onset date June 25-July 24, 2009. Median age of case patients was 18 years (range, 17-24 years). Fever, cough, and sore throat were the most commonly reported symptoms. The incidence rate among basic cadet trainees during the outbreak period was 11%. Twenty-nine percent (31/106) of samples from patients with temperature <100 degrees F and 19% (11/58) of samples from patients reporting no symptoms for > or = 24 hours contained viable nH1N1 virus. Of 29 samples obtained 7 days from illness onset, seven (24%) contained viable nH1N1 virus. CONCLUSIONS: In the nH1N1 outbreak under study, the number of cases peaked 48 hours after a social event and rapidly declined thereafter. Almost one quarter of samples obtained 7 days from illness onset contained viable nH1N1 virus. These data may be useful for future investigations and in scenario planning.

Therapeutic management, delivery, and postpartum risk assessment and screening in gestational diabetes.

OBJECTIVES: We focused on four questions: What are the risks and benefits of an oral diabetes agent (i.e., glyburide), as compared to all types of insulin, for gestational diabetes? What is the evidence that elective labor induction, cesarean delivery, or timing of induction is associated with benefits or harm to the mother and neonate? What risk factors are associated with the development of type 2 diabetes after gestational diabetes? What are the performance characteristics of diagnostic tests for type 2 diabetes in women with gestational diabetes? DATA SOURCES: We searched electronic databases for studies published through January 2007. Additional articles were identified by searching the table of contents of 13 journals for relevant citations from August 2006 to January 2007 and reviewing the references in eligible articles and selected review articles. REVIEW METHODS: Paired investigators reviewed abstracts and full articles. We included studies that were written in English, reported on human subjects, contained original data, and evaluated women with appropriately diagnosed gestational diabetes. Paired reviewers performed serial abstraction of data from each eligible study. Study quality was assessed independently by each reviewer. RESULTS: The search identified 45 relevant articles. The evidence indicated that: Maternal glucose levels do not differ substantially in those treated with insulin versus insulin analogues or oral agents. Average infant birth weight may be lower in mothers treated with insulin than with glyburide. Induction at 38 weeks may reduce the macrosomia rate, with no increase in cesarean delivery rates. Anthropometric measures, fasting blood glucose (FBG), and 2-hour glucose value are the strongest risk factors associated with development of type 2 diabetes. FBG had high specificity, but variable sensitivity, when compared to the 75-gm oral glucose tolerance test (OGTT) in the diagnosis of type 2 diabetes after delivery. CONCLUSIONS: The evidence suggests that benefits and a low likelihood of harm are associated with the treatment of gestational diabetes with an oral diabetes agent or insulin. The effect of induction or elective cesarean on outcomes is unclear. The evidence is consistent that anthropometry identifies women at risk of developing subsequent type 2 diabetes; however, no evidence suggested the FBG out-performs the 75-gm OGTT in diagnosing type 2 diabetes after delivery.