Tuesday, January 31, 2017

ASRM and SREI issues guidelines to optimize natural fertility in absence of evidence of infertility.


American Society for Reproductive Medicine(ASRM) in collaboration with the Society for Reproductive Endocrinology and Infertility(SREI) issued counseling guidelines for achieving pregnancy in couples who are perfectly normal or no abnormality is detected in any test results.

These guidelines were published in January,2017 issue of Fertility and Sterility. [1]

The guidelines and recommendations are:

1) Fertility declines with increasing age in women and women > 35 years of age should be advised to consult a physician if they do not achieve pregnancy after 6 months of uninterrupted intercourse. For women < 35 years the time window is 12 months.

2) Specific recommendations regarding frequency of intercourse brings in unnecessary tension among couples. But, reproductive efficiency is maximum if intercourse occurs every 1-2 days, but the couple should be counseled about it and advised to follow “their own preference” within the context.

3) The fertile window in the cycle is best defined as the 6 days’ period that ends on the day of ovulation, because viability of both sperms and ovum is maximum during that time. Chances of fertilization is highest if intercourse occur on the day prior to ovulation.

4) Most postcoital practices adopted by couples like lying supine after intercourse and avoiding using the bathroom has no scientific backup. Some commercially available vaginal lubricants inhibit sperm motility by as much as 60- 100% in vitro but no results in vivo. But if needed mineral oil, canola oil, or hydroxyethylcellulose-based lubricants should be recommended during this time.

5) Fertility decreases at the extremes of BMI but, variations in daily diet or any specific diet does not have an effect on the fertility. Healthy eating may help improve fertility and diet high in mercury because of seafood consumption is known to be associated with infertility.

6) Women who are trying to conceive should receive 400 mcg of folic acid daily.

7) Smoking has very deleterious effect on fertility with the odds decreasing by 60% in women who smoke and increasing the rates of miscarriage. Smoking also causes rapid follicular atresia accelerating the occurrence of menopause.

8) Alcohol and caffeine in heavy doses have a deleterious effect on pregnancy and should be avoided. That amounts to > 2 drinks/day, with 1 drink >10 g of ethanol for alcohol and 500 mg; >5 cups of coffee/day per day. Moderate coffee consumption of 1-2 cup per day have no effect.

9)Similarly, recreational drugs, environmental pollutants and toxicants are all recognized to decrease fertility and exposure to them should be avoided.

The full text of the article can be accessed from here.

[1] http://www.fertstert.org/article/S0015-0282(16)62849-2/fulltext

Monday, January 30, 2017

Mother’s Cervicovaginal microbiota could be the key to prevent Spontaneous Preterm Births--News from SMFM 2017, Las Vegas.

Courtesy: CDC

More exciting news from the pregnancy meeting, SMFM 2017, Las Vegas. Researchers have identified that maternal cervicovaginal (CV) flora plays an important role in timing of delivery, it could increase or prevent the risk of Spontaneous Preterm Births (SPTB).  

The study abstract was presented on January 26,2017 at the meeting and won the March of Dimes award for best abstract on prematurity.

This was a nested study of a large project called as “Motherhood and the Microbiome” that was funded by National Institute of Nursing Research (NINR). This is a large observational, prospective study of women with a term birth undergoing follow up for Preterm Births.

Dr. Elovitz, professor of Obstetrics and Gynecology at the University of Pennsylvania, vice chair of Translational Research and Director of the Maternal and Child Health Research Center at PENN University and his colleagues worked on the hypothesis that preterm birth occurs because of some changes at molecular, anatomical and microbial level in the cervicovaginal space that are different in women who have a SPTB vs. women who deliver at term.

The study recruited about 1500 patients and collected cervicovaginal specimens at 3 time points throughout pregnancy. From this larger pool of participants, 80 cases with SPTB and 320 term controls were matched and analyzed. 16S rRNA gene analyses was used to identify bacterial specimens.

Additionally, in 616 patients single sample was collected to serve as validation.

Presence of Bifidobacterium species in the cervicovaginal space was highly protective for SPTB at all time while BV-associated bacteria (BVABs) and Mobiluncus were associated with statistically significant rise in SPTBs. (p<0.0001).

Edward R.B. McCabe, MD, PhD, senior vice president and chief medical officer of the March of Dimes said “From these data, we may learn how to prevent preterm birth either by eliminating the CV bacteria that are associated with an increased risk and/or by enhancing the presence of protective bacteria. This is a promising new area that should become a research priority.”

Sunday, January 29, 2017

The best agent to prevent preeclampsia: A systematic review and network meta-analysis--News from SMFM 2017, Las Vegas.

Calcium supplements 
Out of various agents used for prevention of preeclampsia calcium supplementation has got the highest likelihood of being successful in bringing down its incidence and perinatal mortality as per a study presented by Sanchez-Ramos L. et al. at the pregnancy meeting, SMFM 2017, Las Vegas.

Preeclampsia complicates approximately 3-5% of pregnancies, accounting for 10-15% of maternal deaths and 3% of perinatal deaths.

Numerous agents have been studied for their ability to prevent preeclampsia and conventional studies have gauged the effectiveness of these agents. But these have been small, single center trials.

This was a systematic review and network meta-analysis of large RCTs comparing the effectiveness of multiple treatment options in preventing preeclampsia. Only data from meta-analysis of large RCTs with more than 450 subjects were included.

The study was registered under PROSPERO,[1] an international prospective register of systematic reviews in areas of healthcare all around the world and guided by PRISMA guidelines.[2]

A search of electronic databases from 1966 through July15, 2016 picked up 27 large multicenter trials with total of 60, 425 pregnant women. This large cohort was used to compare various exposures against Placebo or no treatment for the development of preeclampsia. The secondary outcome studied were severity of preeclampsia and maternal and neonatal morbidity and mortality. The various agents studied were:
  • Low-dose aspirin: aspirin given at low doses (50-100mg) during pregnancy
  • Calcium supplementation: given at doses of 500-2000mg
  • Low molecular weight heparin: anticoagulant
  • Vitamin E/C: vitamin supplements in varying doses as defined by the study
  • Fish oil: supplement derived from fatty tissue of fish containing omega-3 fatty acids

Direct and indirect pairwise comparison was done using STATA for multivariate random effect models.

It was seen that women who regularly received Calcium supplementation had a 61% and 74% less odds of developing preeclampsia in direct and indirect comparison.

Women receiving calcium supplementation has 68% less likelihood of developing preeclampsia as compared to women receiving fish oil.  

Taking Calcium was also associated with less chances of perinatal mortality as compared to low-dose aspirin, vitamins C & E, and placebo. 

[1] https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/2046-4053-1-2
[2] http://www.prisma-statement.org/

Saturday, January 28, 2017

YO, a FDA cleared smartphone based app that enables sperm test from comfort of your home.

Courtesy: yospermtest.com

Studies indicate that 30% of infertility cases are related to male reproductive issues. The impact of  being diagnosed as infertile or sub fertile and repeatedly going to pathology lab for tests is like a roller-coaster journey for men. They are often reluctant to get the needed pathological test done, especially the semen analysis.

Medical Electronic System (MES) recently announced the launch of its Yo Home Sperm Test, unsurprisingly the first sperm tester to be powered by a smartphone application.  

MES is a Los Angeles based company specializing in rapid automated sperm analysis systems. All the products are CE and FDA cleared and are sold through extensive worldwide network of   distributors. [1]

The YO Sperm Test uses an app and a detachable mini-microscope "clip" that fits on the top of your I phone or Samsung phone. The device uses phone’s light, focus and recording system.

The testing kit includes everything needed, including the sample collection cup, slide, pipette and liquefying powder.

The patient has to prepare a sample on the slide and insert it into the clip, and in 2 minutes you can actually visualize the motility of sperms on the screen and save the video. The result will be ready in another minute and will be stored in the app along with the video.

Marcia Deutsch, CEO of Medical Electronic Systems says "The technology is able to read the sperm sample 99 percent of the time, as long as the instructions are followed. [If it can read the test] the results are more than 97 percent accurate based on FDA studies of 316 participants."

The tests also report motility according to WHO guidelines of sperm motility as low, moderate or normal. [2]

The YO sperm test does not replace a lab results as it does not give us any idea about sperm morphology. But, it gives 97% accurate results for those who do not want to go to a doctor or lab.

It’s available from the Medical Electronic Systems website, two testing sets come together in a box and will cost $49. It will be available in the market from January 31, 2017.

The other sperm test SpermCheckFertility Home Sperm Test is available in US market since 2012.

[1] http://www.newswise.com/articles/medical-electronic-systems-announces-the-release-of-the-new-sqa-vision-automated-sperm-quality-analyzer
[2] http://www.aab.org/images/aab/pdf/2014/crbppt14/who.pd

Friday, January 27, 2017

Model developed to predict chances of vaginal delivery in nulliparous women undergoing induction of labor-- News from SMFM 2017, Las Vegas.


According to statistics by CDC, 23.3% of women in USA undergo induction of labor making it one of the most common obstetric procedure performed in US hospitals.

A study presented at the 37th  annual meeting of Society for Maternal-Fetal Medicine , January 23-28 , Las Vegas by Dr. Tetsuya Kawakita and his colleagues sought to  develop a model that could predict  the likelihood of successful induction of labor. [1]

The researchers used data from Consortium on Safe labor study, a retrospective multicenter study that extracted data on labor and delivery across 19 hospitals in United states. [2]

Of 12,413 nulliparous women at ≥37 weeks’ gestation who had labor undergone induction, 9,550 (76.9%) delivered vaginally.

The researchers studied the various demographic, obstetric and neonatal factors in these study group and by running stepwise logistic regression were able to identify factors associated with successful vaginal birth.

The maternal factors were maternal age, BMI, race, weeks at induction, gestational diabetes or prediabetes, cervical dilatation, effacement and consistency.  Fetal factors were station of fetal head, amount of liquor, IUGR and CTG at the beginning of the procedure. Taking all these factors into account a Nomogram was created, each maternal factor was allotted a fixed number of points. A maternal BMI of 70 received 8 points while a BMI of 20 received 95 points. Similarly, if maternal age at labor was 45 she received 4 points while 25 points were given if her age was 20.

The total points were calculated with a maximum of 317 points. The higher the number of points the patient received, the probability of vaginal delivery also increased.  

Adapted from SMFM 2017 abstracts 

[1] http://www.ajog.org/article/S0002-9378(16)31917-2/fulltext
[2] https://www.nichd.nih.gov/about/org/diphr/eb/research/Pages/safe-labor.aspx

Thursday, January 26, 2017

A novel ultrasound parameter help predicts mid-trimester cerclage failure-- -- News from SMFM 2017, Las Vegas.

UCA  acute and obtuse Courtesy Researchgate 

Increasingly wide utero cervical angle (UCA) after mid trimester cerclage operation signifies increase risk of preterm delivery.

Dr. Jordan Knight and his colleagues from Indiana University School of Medicine, Indianapolis, IN presented a pilot study, utilizing UCA in predicting the failure of mid-trimester transvaginal cerclage operations. [1]

UCA is defined as the triangular area between the lower uterine segment and cervical canal measured by Transvaginal Ultrasonography (TVUS).

Researchers are exploring the possibilities of using a novel ultrasound parameter, the anterior utero cervical angle (UCA) as a predictor of Spontaneous Preterm Birth along with Cervical length (CL). Previously this angle has been used as one of the parameter for successful induction of labor.

The pathophysiological   principle behind this is based on physics and trigonometry. Pregnant uterus exerts pressure on cervix and depending on the angle of inclination, the cervix is either shut if the angle is acute or opened wide if the angle is obtuse.

The current retrospective study collected data on 142 women who underwent transvaginal cerclage between 2010-2015. UCL was measured thrice in same patient: prior, one week after cerclage placement and prior to delivery by TVUS.

Delivery before 36 weeks was labelled as cerclage failure.

After Univariate regression, it was seen that CL and UCL was strongly associated with gestational age at birth.

UCL angle of 108 degree prior to 34 weeks was a better predictor of preterm delivery than CL = 25 mm. Before28 weeks the UCL angle of 112 degree had 100 sensitivity as compared to 29% that of CL.

Patients with UCA angle> 108 degree had 35 times higher odds of spontaneous preterm birth (PTB) before 34 weeks while the UCL > 112 degree conferred 42 times higher odds of delivering before 28 weeks.

The corresponding odds of delivery if cervical length CL<25mm are 4.7 and OR 6.0 prior to 34 and 28 weeks respectively.

The study cohort had 38% cerclage failure rate and delivered at mean gestational age of 29 +/- 5.2 weeks compared to those who delivered at 37.9 +/- 2.8 weeks (p<0.001).

A study presented at the 36th Annual Pregnancy Meeting concluded that “A wide uterocervical angle ≥95 and ≥105 degrees detected during the second trimester was associated with an increased risk for spontaneous preterm birth <37 and <34 weeks, respectively. Uterocervical angle performed better than cervical length in this cohort.”[2]

The authors concluded that increasing obtuse UCA signify increase chances of cerclage failure and give the obstetrician valuable time to make arrangements for delivery at tertiary center.
UCA performed better than CL as a screening parameter for predicting preterm births (PTB) because of increased sensitivity and NPV.

In fact, a combination of UCA and CL synergistically can be best predictor of PTB in cerclage patients.

[1] http://www.ajog.org/article/S0002-9378(16)31012-2/fulltext
[2] http://www.ajog.org/article/S0002-9378(16)00525-1/abstract

Wednesday, January 25, 2017

Similar results obtained after use of Glue or subcutaneous Monocryl for cesarean wound closure -- News from SMFM 2017, Las Vegas.

Skin glue: Ethicon.com 


Use of Glue(Dermabond ) or subcutaneous  Monocryl results in same outcome in terms of safety, healing,  wound complications or cosmetic appearance. The choice of using one over another depends on surgeons’ choice and patient’s preference.

The study will be presented at the 37th  annual meeting of Society for Maternal-Fetal Medicine , January 23-28 , Las Vegas. Cesarean sections rates are on rise, it is the most common surgery performed in U.S. hospitals. Roughly, every one in three baby is born by Cesarean Section. In-spite this, there is still no consensus or evidence about best method for skin closure in Cesarean section.

Yari Daykan and his colleagues from Dept. of Obstetrics and Gynecology at Meir Medical Center in Kfar Saba and the Sackler School of Medicine in Tel Aviv conducted a RCT, in which women undergoing a scheduled Cesarean section were randomized to either have the wound glued using Dermabond or wound closed by using subcuticular Monocryl. [1]

The scars were assessed after 2 months by using Patient and Observer Scar Assessment Scale (POSAS) scores.   The POSAS is a comprehensive scale that is designed for the evaluation of all types of scars by professionals and patients.[2]

The scar site was also evaluated at 1 month for infection, discharge, redness or dehiscence as secondary outcome of the study.

Both the study groups were comparable in terms of indications for C-section, length of surgery, BMI and other demographics.

It was seen that at 8 weeks, scars were comparable in terms of patient score, physician score and subcutaneous thickness, wound infection or wound dehiscence.

Researchers concluded that both methods are safe, equally effective and the choice depends on surgeon and patient's preferences.

[1] http://www.smfmnewsroom.org/2017/01/skin-closure-options-for-cesarean-delivery-glue-versus-subcuticular-sutures/#more-1584
[2] http://www.posas.org/

Use of Monocryl suture minimizes wound complications in cesarean sections - News from SMFM 2017, Las Vegas.

courtesy: https://www.esutures.com/product/images/full/IMG-6441.jpg


Use of poliglecaprone 25 (Monocryl) subcutaneous suture for abdominal wound closure in Cesarean Section reduces the wound complication rate by nearly 50 % as compared to use of polyglactin 910 (coated Vicryl) according to a study that will be presented at the 37th  annual meeting of Society for Maternal-Fetal Medicine , January 23-28 , Las Vegas.[i]

Monocryl is monofilament, absorbable suture which dissolves slowly and loses strength while Vicryl is braided, absorbable suture  that dissolves quickly but maintain strengths.

The first ever Randomized control trial was conducted by Dr. Arin Buresch and her colleagues from Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY.[ii]

Over a course of little more than a year, 550 patients undergoing non-emergency cesarean section were recruited and randomly allocated to either receive poliglecaprone(275() or 275 receiving polyglactin for subcutaneous wound closure of the Pfannenstiel abdominal incision.

The groups were comparable demographically. These patients were evaluated and compared at 30 days for wound gaping of > 1 cm in length, hematoma or seroma and surgical site infections as per Centers for Disease Control and Prevention criteria’s.

8.8% patient had wound complication in poliglecaprone 25 (Monocryl) group as opposed to 14.4% patient in Vicryl group (p=.04).

Dr. Arin Buresch concluded “The difference in wound complications may occur due to the braiding in vicryl suture which conceivably allows bacterial growth in small nooks and crevices. In the future, we hope our study will help guide the decision-making on which suture type is used when closing the skin in cesarean births.”

[i] https://www.smfm.org/meetings/2-37th-annual-pregnancy-meeting/registration
[ii] http://www.smfmnewsroom.org/2017/01/comparing-skin-closure-options-for-cesarean-delivery-to-determine-which-method-causes-the-least-wound-complications/#more-1609

Tuesday, January 24, 2017

Designer babies: an ethical horror or scientific boon

Designer babies: intelligent, perfect on all account with no flaws is no longer a part of science fiction. They are real and here to stay. The latest development of crisper technology has made it possible to design embryos according to the demand.

As scientific and ethical arguments over ‘three parent babies’  go on, designer babies are not far behind in the line.

Creating genetically modified people is no longer a science fiction fantasy; it's a likely future scenario. Biologist Paul Knoepfler estimates that within fifteen years, scientists could use the gene editing technology CRISPR to make certain "upgrades" to human embryos — from altering physical appearances to eliminating the risk of auto-immune diseases. In this thought-provoking talk, Knoepfler readies us for the coming designer baby revolution and its very personal, and unforeseeable, consequences.

A worth listening Ted talk by the famous biologist Paul Knoepfler.

SMFM recommendations for routine cervical length screening for preventing Preterm Births.

Courtesy: Pixabay 

A summary of Society for Maternal-Fetal Medicine  recommendation for Cervical Length ( CL) screening to prevent Preterm births. 

Preterm birth (PTB) remains a major cause of neonatal death and short and long term disability across the globe. The current global preterm birth rate is 5% to 18% and statistic shows a steady increase recently. CDC data quotes that in the year 2014, every 1 in 10 infants was born preterm in US. 

 Nearly 2/3 of 15 million preterm births are spontaneous with a very high recurrence. A history of previous PTB is the strongest risk factor for preterm delivery in the current pregnancy. Among various other contributing factors prior uterine surgery, especially those performed on cervix (induced termination of pregnancy (I-TOP) or spontaneous abortion (SAB)) has been implicated in its causation.

There are few laboratory tests to predict preterm birth in a pregnancy.

Transvaginal Cervical Length measurement helps in predicting the risk of preterm birth so the obstetrician and his team gets time to intervene, delay or transfer the patient to high risk units.
At present, a single mid-trimester transvaginal CL measurement is the best clinical predictor of a preterm birth. Those with the shortest cervix has the highest risk of prematurity.

The Society for Maternal-Fetal Medicine issued recommendation about the role of routine cervical length screening in selected high-and low-risk women for preterm birth prevention.

  • SMFM recommends “routine transvaginal cervical length screening for women with singleton pregnancy and history of prior spontaneous preterm birth (GRADE 1A).”

Transvaginal assessment at 16 and 24 weeks’ gestation by a trained sonologist or obstetrician should be performed. Routine CL screening is not advisable before 16 weeks and after 24 weeks in asymptomatic women.  

In women with prior history of preterm births serial CL measurements are performed every week beginning at 16 weeks to 24 weeks.

  • SMFM recommends “Practitioners who decide to implement universal CL screening should follow strict guidelines (GRADE 2B).”
  • SMFM recommends “Routine transvaginal CL screening not be performed for women with cervical cerclage, multiple gestation, PPROM, or placenta previa (GRADE 2B).”

Evidence does not support additional screening for women who have undergone cervical conning or LEEP beyond the standard recommendations.

No additional clinical benefit is derived for repeated CL screening in women who have undergone cerclage operation. Although research demonstrates that progressive CL shortening after the stitch increases the risk for PTB, but no options exist to reinforce the short cervix after cerclage.

Routine cervical screening is not recommended by SMFM in multiple gestation as no additional clinical benefit is derived from it.

Transvaginal CL measurement serves as an adjunct to fetal fibronectin (FFN) in predicting PTB in women with CL of 20-29 mm (the grey zone). Cervical length more than 30 mm and less than 20 mm is independently a strong predictor of minimum chances for PTB or high risk for  PTB respectively. 

Not much clinical benefit is derived from cervical length estimate in Preterm premature rupture of membranes (PPROM). Few observational studies have shown that with a transvaginal CL <2 cm, the positive predictive value of delivery within 7 days was 62%.

Routine transvaginal CL measurement is not performed in case of placenta previa as studies do not show any additional benefit is derived for management.
  • SMFM recommends “sonographers and/or practitioners receive specific training in the acquisition and interpretation of cervical imaging during pregnancy”.

Steps for proper cervical length measurement as recommended by SMFM.[1]

(1) Ensure patient has emptied her bladder.
(2) Prepare the cleaned probe using a probe cover.
 (3) Gently insert the probe into the patient’s vagina.
 (4) Guide the probe into the anterior fornix.
 (5) Obtain a sagittal, long-axis image of the entire cervix.
(6) Remove the probe until the image blurs and then reinsert gently until the image clears (this ensures you are not using excessive pressure).
(7) Enlarge the image so that the cervix occupies two thirds of the screen.
 (8) Ensure both the internal and external os are seen clearly.
 (9) Measure the cervical length along the endocervical canal between the internal and external os.
(10) Repeat this process twice to obtain 3 sets of images/ measurements.
(11) Use the shortest best measurement.

[1] SMFM. Role of routine cervical length screening for preterm birth prevention. Am J Obstet Gynecol 2016.

Monday, January 23, 2017

Everything you need to know about Herpes type 1 and type 2.

courtesy: rschealth.com

Herpes simplex virus is still a mystery for researchers and physician because they have yet to explore many things about it. The word ‘Herpes’ have its origin in Greek language and means ‘to crawl or to creep’, a name perfectly suited because once the cells are infected, the virus ascends the nerve pathways to reach dorsal root ganglia and lie dormant there, only to resurface and cause infection sporadically.

Besides Herpes Simplex that causes sexually transmitted diseases, other common Herpes strains include chicken pox or shingles (caused by herpes zoster virus) and Kaposi’s sarcoma (caused by herpes virus 8). 

Herpes simplex primarily infect mouth and genitals and spread by bodily fluids. Two type of Herpes Simplex Viruses are commonly seen in clinical practice: herpes type 1 (HSV1) and herpes type 2 (HSV2).

Herpes Virus type 1

HSV1 is highly contagious  infection. It is endemic  throughout the globe but the age of primary infection varies according to geography. In African subcontinent majority of infection is acquired in childhood  while in America, Europe and western Pacific seroconversion continues well into adulthood.It is  mainly transmitted by oral-to-oral contact to cause oral herpes infection via infected sores, body fluids or surfaces. The oral lesion is  commonly known as cold sores, however it can cause genital herpes due to oral-genital contact too.

A person who has a history of HSV 1 oral herpes infection is unlikely to get HSV1 genital infection in future, but he /she is still at risk of getting HSV2 genital infection.

If a person with Genital Herpes tests positive for HSV1, then there is less chance of infecting the partner The frequency of sporadic shedding and recurrence is much less too in  HSV type 1 infection.

HSV1 is vertically transmitted from mother to fetus if the women acquire genital infection for the first time in late pregnancy. Risk of transmission is very less if she was already infected before pregnancy. She should inform her obstetrician if she gets infected late in pregnancy.

In HIV, infected population HSV1 is known to cause more serious infections and frequent recurrences due to Immunocompromised state. Sometimes, it can cause keratitis and encephalitis.

Herpes Virus type 2

HSV2 is also a  global issue, it is exclusively transmitted sexually, causing genital ulcers or blisters. Its prevalence is highest in African subcontinent where nearly 32% population is harboring the virus. More women are infected with HSV2 than men because men to women transmission is more efficient than women to men.

Herpes simplex virus digital image 

After the first infection and seroconversion, recurrent infections are mild and infrequent, decreasing over time.

It is primarily transmitted through sexual contact with sores, ulcers or bodily fluid of an infected person. Rarely, vertical transmission has also been documented.

People infected with HSV2 are at 3 times higher risk for getting HIV infection. About 60-90% of HIV infected people are also test positive for HSV2.

Contrary to the popular belief that Herpes 1 only infect above the waist and Herpes 2 infect below the belt, Herpes 1 is perfectly capable of causing genital infection and more than half of new genital herpes cases are caused by type1. Similarly, Herpes type 2 can cause cold sores.

According to a 2012 fact sheet by WHO, globally 3709 million (67%) people aged 0-49 have Herpes type 1[1] while 417 million (11.3%) people aged 15–49 years have Herpes type 2.[2] Almost 1 in 6 people in US, aged 15-49 years have Herpes type 2 infection and most people are unaware of it because the symptoms are very mild.

Herpes is a lifelong infection with mild or no symptoms at all making it difficult to estimate the burden of disease. The virus remains dormant in the dorsal root ganglia for unknown period of time and becomes active again and resume shedding. About one-third to half of people who shed virus have no symptoms at all and are being responsible for 70% of transmission.

Both Herpes 1 and 2 can cause cold sores and genital infection but majority of cases of cold sores are caused by Herpes1 and majority of genital infections by Herpes2. This is very important from the point of recurrence, because if Herpes 2 causes you cold sores, it is far less likely to recur and shed the virus sporadically and same holds true for Herpes 1 causing genital infection. They do best when they are in their natural habitat.

The initial orolabial and genital blisters are very severe and subsequent attacks are often very mild and may not cause any symptoms also.

Treatment consists of antivirals like acyclovir, famciclovir, and valaciclovir. They only reduce the severity of symptoms but do not cure the infection.

‘Prevention is the best cure’ paradigm holds good for Herpes Simplex infection. Using barrier methods for protection along with abstaining from sex during symptoms of genital herpes reduces the risk of transmission. Vertical transmission can be prevented by sharing information with the obstetrician. Males undergoing circumcision are at 50% less risk of infection with HSV2, HIV and HPV.[3]

Research is underway to develop vaccines or topical microbicides to prevent the spread of Herpes.   

Herpes and Pregnancy:

According to ACOG

Women who have genital herpes infection late in pregnancy and have a vaginal birth have 30-50% chances of infecting the fetus.

First episode occurring late in pregnancy also have high chances of vertical transmission as opposed to recurrent infection (2-5% chances).

Neonatal infection with Herpes simplex occur in 1in 3500-10,000 livebirths in USA, mostly to those women with asymptomatic or unrecognized infection.

Maternal infections are classified into:

  1. Genital infection is labelled as ‘primary’ when the patient is seronegative for both HSV-1 and HSV-2.
  2. It is labelled as ‘nonprimary first’ when it occurs in patient with prior history of heterologous infection (HSV2 in patient who had prior HSV1 infection and vice versa).
  3. Recurrent when it occurs with clinical or serological evidence of prior genital herpes.  

Misconceptions are rife among physician, researchers, laboratory personnel and patients about ordering and interpreting lab reports for Herpes.  That is the  topic for next article on the blog.

[1] http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0140765
[2] http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0114989

Saturday, January 21, 2017

‘Weekend warriors’ workout tied to longevity with low risk for CVD, cancer and all-cause mortality.

Courtesy: Pixabay

The standard recommendation by CDC[1] and American Heart Association[2] is 150 minutes of moderate or 75 minutes of vigorous physical activity per week for achieving health benefits for those aged 18 to 64 years. But, very few people can keep up with this routine and most of us just cram the workout of entire week into 1- 2 weekend sessions, 2-3 long runs or participating in our favorite sports like hiking, basketball or Zumba.

Courtesy: Pixabay

Well, although not ideal but, it reduces your risk of dying from cardiovascular, all cause and cancer by 30% according to a new study published in JAMA Internal Medicine online on January 9, 2017.[3] The study was conducted by researchers from the National Centre for Sport and Exercise Medicine–East Midlands at Loughborough University in the United Kingdom.

This study examined whether ‘weekend warriors’ also derive the same benefits as their more active, regularly hitting the gym counterparts.

Gary O’Donovan did a pooled analysis of 63 591 adult respondents (>40 years old) who answered a household based survey in England and Scotland. The survey was conducted between 1994 to 2012 and analyzed in 2016. The survey was prospectively linked to British National Health Service Central Registry which identified participants who died, including the cause of death.

For the purpose of analysis, the respondents very divided into 4 groups depending on their exercise pattern:  Those who  were inactive (reporting no moderate- or vigorous-intensity activities), insufficiently active (reporting <150 min/wk in moderate-intensity and <75 min/wk in vigorous-intensity activities), weekend warrior (reporting ≥150 min/wk in moderate-intensity or ≥75 min/wk in vigorous-intensity activities from 1 or 2 sessions), and regularly active (reporting ≥150 min/wk in moderate-intensity or ≥75 min/wk in vigorous-intensity activities from ≥3 sessions). 

The mean age of the study participants was 58.6 years with nearly equal gender ratio. About 40,000 people did not exercise at all, 14000 were insufficiently active, 2500 were weekend warriors and 7000 people were regularly active.

During the follow up period of 9 years, 8,800 people died, CVD being responsible for 2780 and cancer for 2500 deaths.

A detailed analysis of ‘weekend warriors’ group showed that, men were more likely to work vigorously on weekends, mostly engaging in some sort of sports. Walking briskly was also very popular and reported by 30% of weekend warriors. Weekend warriors spent a total of 300 minutes exercising as compared to 450 minutes spent by those who are regular.

After adjustment for all confounders, as compared to inactive participants risk of all cause death for weekend warriors was 30% less (hazard ratio [HR], 0.70), risk of CVD was 40%( HR=0.60) less and cancer death was 18% less (HR= 0.82).

Similar pattern of risk reduction was found in insufficiently active people too, indicating any exercise is better than being totally inactive.

When analysis was run between inactive group and regular exercise group, the regularly active persons have a 35% decrease in all-cause mortality (HR=0.65),  41% lower CVD death(HR=0.59), and 21% lower cancer death(HR=0.79).

During the follow up period of 9 years, 8,800 people died, CVD being responsible for 2780 and cancer for 2500 deaths.

"These findings suggest that some physical activity in an isolated session, or low activity, is certainly better than no activity for reducing mortality risk," Hannah Arem and Loretta DiPietro, of George Washington University, wrote in a commentary accompanying the new study in the journal.

The study has its own limitations that it is dependent on self-reporting and assessed the activity level only once at the start of the study. The study also did not assess the risk of injury in the weekend warriors.

But, the encouraging new conclusion emerging from the study is for those who exercise less frequently is even 1-2 vigorous activity session per week have health benefits and can lower the mortality.

The recommendations by CDC for regular physical activity can be found here.

The recommendations by American Heart Association ( AHA)  for regular physical activity can be found here.

[1] https://www.cdc.gov/physicalactivity/basics/adults/
[2] http://www.heart.org/HEARTORG/HealthyLiving/PhysicalActivity/FitnessBasics/American-Heart-Association-Recommendations-for-Physical-Activity-in-Adults_UCM_307976_Article.jsp#.WIPgqBsrK00
[3] http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2596007