Valproate prescription to women of childbearing age in English primary care: repeated cross-sectional analyses and retrospective cohort study

Background

Valproate is a teratogenic drug that should be avoided during the preconception period and pregnancy. The aim was to explore general practitioners’ (GPs) prescription patterns over time, describe trends, and explore inter-practice variation within primary care.

Methods

We identified women of childbearing age (12–46 years old) in the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) sentinel network. We performed repeated cross-sectional analyses from 2004 to 2018 to determine rates of prescription and a retrospective cohort estimated the prevalence of use of valproate during pregnancy.

Results

In 2004, 0.31% (95% Confidence Interval (95%CI):0.18 to 0.44%) women were prescribed valproate, decreasing to 0.16% (95%CI:0.07 to 0.24%) by 2018. Among women with epilepsy, the rate fell from 15.2% (95%CI:14.4 to 16.0%) to 8.8% (95% CI:8.2 to 9.7%) over the same period. In 2018, almost two thirds (62.2%) of women who were prescribed valproate had epilepsy only, whereas bipolar disorder and migraine accounted for 15.8% and 7.4% respectively. Contraceptive prescriptions did not increase over time, and only in 2018 was there greater odds of being prescribed contraception (OR 1.41, 95%CI:1.08 to 1.45). Just under a fifth (19.7%) of women were prescribed valproate during their pregnancy; two out of three of these pregnancies were preceded by folic acid prescription (5 mg). While some practices reduced their rate of valproate prescription, others did not.

Conclusions

Regulatory guidelines have changed GPs' prescription patterns in women of childbearing potential for valproate but not for contraception. Further research is needed to identify the barriers of GPs and women of childbearing potential to undertaking contraception.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04351-x.

[Classification of maternal morbidity and mortality using an organic dysfunction scale]

BACKGROUND

The patient with high-risk pregnancy and organic dysfunction is called “critically ill” or “near miss” by the World Health Organization (WHO), generally requiring an intensive care unit (ICU) to avoid death. The WHO establishes its identification through the maternal severity index (MSI). However, this index and other rating scales only detect very high mortality, and not all categories. In order to fully assess the obstetric patient, taking into account different models, gestational parameters, the spectrum of maternal morbidity and treatment, a new scale is proposed to correctly detect and classify maternal morbidity and mortality.

OBJECTIVE

To classify maternal morbidity and mortality using an organic dysfunction scale.

METHOD

Diagnostic and prognostic test validation study. Selection of 80 obstetric patients admitted to the ICU, in a period of 1 year. Scale application by 5 phases: scoring system, detection of multi-organ dysfunction syndrome (MODS), validation of diagnostic test compared to MSI; morbidity and mortality classification. Association, reproducibility and validity tests are performed to determine reliability.

RESULTS

2596 observations were made. The tests support detecting MODS (t Student, P < 0.01) and favor the utility of the scale (sensibility 93%, specificity 65%). The correlation coefficient of the scoring system is positive (0.5274), having >12 points (>50%) emits the highest risk.

CONCLUSIONS

The new scale adequately detects the MODS and allows an objective classification of the degree of maternal morbidity and mortality.

Cesarean Scar Pregnancy Successfully Managed to Term: When the Patient Is Determined to Keep the Pregnancy

Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy, defined as the implantation of the gestational sac at the uterine incision scar of the previous cesarean section. This condition is associated with severe maternal and fetal/neonatal complications, including severe bleeding, rupture of the uterus, fetal demise, or preterm delivery. In view of these, early diagnosis allows the option of termination of pregnancy. In this case report, we present a patient with a cesarean scar pregnancy who was diagnosed at the sixth week of gestation but declined early termination of the pregnancy and was managed to the 38th week. Placenta previa was confirmed in the second trimester. A planned cesarean section was performed that resulted in the birth of a live full-term neonate. Intraoperatively, placenta percreta was diagnosed, and due to uncontrollable bleeding, a hysterectomy was performed. The postoperative course was uneventful. In cases where an early diagnosis of CSP is made, women should be counseled that this will almost certainly evolve to placenta previa, and the associated risks should be explained. Close follow-up of CSP is mandatory if expectant management is selected. Further studies are needed for definitive conclusions and to determine the risks of expectant management.

[Treatment of postpartum arterial hypertension with losartan in severe preeclampsia]

BACKGROUND

Postpartum hypertension increases the risk of acute and chronic complications in patients with preeclampsia. Losartan may be a useful drug alternative.

OBJECTIVE

To determine the results of treatment of postpartum hypertension with losartan in patients with severe preeclampsia.

METHOD

Uncontrolled clinical trial in 49 patients with severe preeclampsia. After gestational interruption, two groups were formed: group A (n = 24) received the standard antihypertensive regimen (methyldopa 1500 mg/day, hydralazine 200 mg/day, metoprolol 200 mg/day), and group B (n = 25) the same treatment plus losartan 100 mg/day for 90 days. In both groups, methyldopa, hydralazine and metoprolol was reduced or suspended in that order; in group B, losartan was maintained with the same or half the dose without suspending it. Baseline and final values (day 90) of systolic (SBP) and diastolic blood pressure (DBP) were compared. Descriptive and inferential statistics were applied (Student's t test for paired samples, Mann-Whitney U test, Wilcoxon's signed rank test). It was significant a p < 0.05.

RESULTS

Group A: baseline SBP 135.46 ± 13.88 vs. final 109.76 ± 10.54 mmHg (p < 0.001) and basal DBP 85.71 ± 10.17 vs. final 72.14 ± 10.55 mmHg (p < 0.001). Group B: basal SBP 135.84 ± 14.39 vs. final 110.68 ± 9.79 mmHg (p < 0.001) and baseline DBP 83.08 ± 9.58 vs. final 72.61 ± 9.16 mmHg (p < 0.001).

CONCLUSIONS

Both treatments similarly reduced SBP and DBP at the 90-day measurement.

Comparison of four scoring systems for risk stratification of upper gastrointestinal bleeding

Objective:

This study aimed to compare the performances of the Glasgow–Blatchford Bleeding Score (GBS), pre-endoscopic Rockall score (PRS), complete Rockall score (CRS), and Cedars–Sinai Medical Center Predictive Index (CSMCPI) in predicting clinical outcomes in patients with upper gastrointestinal bleeding (UGIB).

Methods:

Patients who were admitted to the emergency department because of UGIB and underwent endoscopy within the first 24 hour were included in this study. The GBS, PRS, CRS, and CSMCPI were propectively calculated. The performances of these scores were assessed using a receiver operating characteristic curve.

Results:

A total of 153 patients were included in this study. For the prediction of high-risk patients, area under the curve (AUC) was obtained for GBS (0.912), PRS (0.968), CRS (0.991), and CSMCPI (0.918). For the prediction of rebleeding, AUC was obtained for GBS (0.656), PRS (0.625), CRS (0.701), and CSMCPI (0.612). For the prediction of 30-day mortality, AUC was obtained for GBS (0.658), PRS (0.757), CRS (0.823), and CSMCPI (0.745).

Conclusion:

These results suggest that effectiveness of CRS is higher than that of other scores in predicting high-risk patients, rebleeding and 30-day mortality in patients with UGIB.

The relationship between cannabis use and cortisol levels in youth at ultra high-risk for psychosis

Recent studies have posited a relationship between cannabis use and the biological stress system, but this critical relationship has not been evaluated during the ultra high-risk (UHR) period immediately preceding the onset of psychotic disorders. Salivary cortisol samples were collected on 46 UHR and 29 control adolescents; these individuals were assessed for current cannabis use with a urine panel and self-report. UHR participants where separated into two groups: Current Cannabis Use (UHR-CU) and No Current Cannabis Use (UHR-NC). Healthy Control participants (HC) were free of cannabis use. Consistent with the literature, results indicate UHR individuals showed elevated cortisol levels when compared to HC participants. Further, we also observed that UHR-CU participants exhibited elevated levels when compared to both the non-using UHR and HC groups. Findings suggest that cannabis use may interact with underlying biological vulnerability associated with the hypothalamic-pituitary-adrenal (HPA) axis system.

Understanding the Importance of Gene and Environment in the Etiology and Prevention of Type 2 Diabetes Mellitus in High-Risk Populations

Current literature focuses on the complications and treatment of Type 2 Diabetes Mellitus (T2DM) while clustering environmental and genetic factors to explain the disease. Interventions proposed to reduce diabetes prevalence should focus predominantly on initiating active rapports of family members and promoting a more communication-oriented preventative approach between diabetics and non-diabetics. Due to varying risks in T2DM by race and ethnicity, these populations should follow race-appropriate guidelines to prevent further T2DM occurrence and complications. The review consists of information related to the genetic component of T2DM to help identify high-risk groups and focuses on the environmental aspect of the disease to help consider appropriate techniques to reduce disease burden. Genetic factors play important roles in the pathogenesis of diabetes and thus are an essential element of understanding the cause of the disease and possible methods of prevention. Focusing on high-risk groups with T2DM could have profound effects on the current health care situation. In this review, we discuss the epidemiology of diabetes in the United States and propose methods of preventing and delaying the development of T2DM in high-risk individuals.

Amygdala Volume in Offspring from Multiplex for Alcohol Dependence Families: The Moderating Influence of Childhood Environment and 5-HTTLPR Variation

BACKGROUND

The increased susceptibility for developing alcohol dependence seen in offspring from families with alcohol dependence may be related to structural and functional differences in brain circuits that influence emotional processing. Early childhood environment, genetic variation in the serotonin transporter-linked polymorphic region (5-HTTLPR) of the SLCA4 gene and allelic variation in the Brain Derived Neurotrophic Factor (BDNF) gene have each been reported to be related to volumetric differences in the temporal lobe especially the amygdala.

METHODS

Magnetic resonance imaging was used to obtain amygdala volumes for 129 adolescent/young adult individuals who were either High-Risk (HR) offspring from families with multiple cases of alcohol dependence (N=71) or Low-Risk (LR) controls (N=58). Childhood family environment was measured prospectively using age-appropriate versions of the Family Environment Scale during a longitudinal follow-up study. The subjects were genotyped for Brain-Derived Neurotrophic Factor (BDNF) Val66Met and the serotonin transporter polymorphism (5-HTTLPR). Two family environment scale scores (Cohesion and Conflict), genotypic variation, and their interaction were tested for their association with amygdala volumes. Personal and prenatal exposure to alcohol and drugs were considered in statistical analyses in order to more accurately determine the effects of familial risk group differences.

RESULTS

Amygdala volume was reduced in offspring from families with multiple alcohol dependent members in comparison to offspring from control families. High-Risk offspring who were carriers of the S variant of the 5-HTTLPR polymorphism had reduced amygdala volume in comparison to those with an LL genotype. Larger amygdala volume was associated with greater family cohesion but only in Low-Risk control offspring.

CONCLUSIONS

Familial risk for alcohol dependence is an important predictor of amygdala volume even when removing cases with significant personal exposure and covarying for prenatal exposure effects. The present study provides new evidence that amygdala volume is modified by 5-HTTLPR variation in High-Risk families.

Caudate Volume in Offspring at Ultra High Risk for Alcohol Dependence: COMT Val158Met, DRD2, Externalizing Disorders, and Working Memory

BACKGROUND

There is emerging evidence that the increased susceptibility to developing alcohol and substance use disorders in those with a family history of Alcohol Dependence (AD) may be related to structural differences in brain circuits that influence the salience of rewards or modify the efficiency of information processing. Externalizing disorders of childhood including Attention Deficit Hyperactivity Disorder, Conduct and Oppositional Disorders are a prominent feature of those with a positive family history. The caudate nuclei have been implicated in both the salience of rewards and in the pathophysiology of alcohol dependence and these often antecedent childhood disorders.

METHODS

Adolescent/young adult high and low-risk for AD offspring (N = 130) were studied using magnetic resonance imaging. Volumes of the caudate nucleus were obtained using manual tracing with BRAINS2 software and neuropsychological functioning determined. Childhood disorders were assessed as part of a long-term longitudinal follow-up that includes young adult assessment. Dopaminergic variation was assessed using genotypic variation in the catechol-O-methyltransferase (COMT) and DRD2 genes.

RESULTS

High-risk subjects showed poorer Working Memory functioning. Cau-date volume did not differ between high and low-risk subjects, but those with externalizing disorders of childhood showed reduced caudate volume. Variation in COMT and DRD2 genes was associated with Working Memory performance and caudate volume.

CONCLUSIONS

Caudate volume is reduced in association with externalizing disorders of childhood/adolescence. Working Memory deficits appear in familial high-risk offspring and those with externalizing disorders of childhood. The dopaminergic system appears to be involved in both working memory performance and externalizing disorders of childhood.

Exercise intervention in New Zealand Polynesian peoples with type 2 diabetes: Cultural considerations and clinical trial recommendations

The Maori and Pacific Islands peoples of New Zealand suffer a greater burden of type 2 diabetes mellitus (T2DM) and associated comorbidities than their European counterparts. Empirical evidence supports the clinical application of aerobic and resistance training for effective diabetes management and potential remission, but few studies have investigated the effectiveness of these interventions in specific ethnic cohorts. We recently conducted the first trial to investigate the effect of prescribed exercise training in Polynesian people with T2DM. This article presents the cultural considerations undertaken to successfully implement the study. The research procedures were accepted and approved by cultural liaisons and potential participants. The approved methodology involved a trial evaluating and comparing the effects of two, 16-week exercise regimens (i.e. aerobic training and resistance training) on glycosylated haemoglobin (HbA1c), related diabetes markers (i.e. insulin resistance, blood lipids, relevant cytokines and anthropometric and hemodynamic indices) and health-related quality of life. Future exercise-related research or implementation strategies in this cohort should focus on cultural awareness and techniques to enhance participation and compliance. Our approach to cultural consultation could be considered by researchers undertaking trials in this and other ethnic populations suffering an extreme burden of T2DM, including indigenous Australians and Americans.