Georgia Sue Huston knew she was really sick. Every time the 82-year-old woman tried to turn over in her bed in the coronary care unit at Stanford Hospital & Clinics, she’d panic because she couldn’t get enough air and because it hurt so much.

In an effort to ease the pain, Laura Heldebrant asked the hospital’s palliative care team to visit her mother. “I’m an ICU nurse here at Stanford, and I’d seen them help other patients and their families,” she said. “But I didn’t think my mother’s situation was end-of-life.”

It turned out Huston had pulmonary fibrosis-end-stage lung disease. She’d known for some time that she was ill, but she hadn’t been able to get anyone to tell her what the prognosis was. The palliative care team answered her questions. Face to face.

“My mom said, ‘I’ve been wanting to bring this up for a long time, I’ve been wanting to talk about this, but I didn’t know what to say,” Heldebrant recalled. “Once Judy and Dr. Bouvier talked with her, she looked relieved. She went from, ‘Oh, my God, I can’t do this,’ to being at peace.”

Huston told Judy Passaglia, palliative care program director, and Denis Bouvier, MD, palliative care attending physician, that she wanted to be out of the hospital and home with her children and grandchildren for her 83rd birthday. They made arrangements for her to have hospice care at her daughter’s home, and Huston was discharged on Oct. 31. She died 13 days later, in her sleep.

“The important thing is that the palliative care program created an environment that allowed my mom to say what she wanted,” Heldebrant said. “They made her comfortable, so that she could say, ‘I’ve had enough.’”

Deciding how best to care for those who are approaching their final days-and how to support their families-requires a thoughtful understanding of the process of dying and the ability to explain what’s happening as well as provide comfort. “Because palliative care is multidisciplinary, our team works to alleviate suffering beyond just the physical symptoms, acknowledging psychological, social and spiritual needs, as well,” said Stephanie Harman, MD, palliative care medical director. “For many patients, this entails attending to their troubling symptoms, as well as helping them navigate difficult decisions and face advanced disease-and facilitating communication between the patient, their family and their clinicians.”

Harman noted that the goals can vary widely. For some patients and their families, the goal of palliative care is to get out of the hospital and return home-often to hospice care provided by a community agency. Other families want their loved ones to remain in the hospital, taking their final breaths on a ventilator in the ICU.

“Palliative care tries to look at the individual needs of patients and families, and what is going to work for them,” Sandy Chan, palliative care social worker, explained. “We’re not saying, ‘Let’s take everyone off the ‘vent.’ We’re asking what the patient and family’s goals are, and how we can assist in dialogue and interventions that work toward those goals.”

Now in its third year as a consult service in the Department of Medicine, the palliative care program gets requests from physicians to see patients from virtually all nursing units. They typically consult on 45 patients per month. “The primary team of neurologists or oncologists may talk with a patient about the elements of a stroke or the progression of the cancer, and we’re there to listen and to support the patient through the process,” Passaglia said.

The palliative care team typically includes an attending physician, a physician fellow, an advanced practice nurse physician and a clinical social worker. If the primary care team slips into medical jargon, palliative care clinicians can translate confusing numbers and procedures into lay terms. “We’ll ask, ‘Is this going to extend this person’s life, or not?’ and, ‘How is this going to impact care-giving at home?’” Passaglia said. “So that it’s very clear what’s being talked about.”

When a patient has limited time because of a devastating disease, Harman said a palliative care approach gives the patient control over how he spends his remaining time-often trying to weigh quality of life, versus quantity of life. “Research in the 1990s demonstrated that we as a health care system were not taking into account patients’ preferences for end-of-life care,” she added. “Palliative care does not preclude ongoing curative treatments, but rather serves to complement a patient’s ongoing care with symptom management and support.”

Palliative care became a recognized sub-specialty of medicine in 2008, and physicians like Harman can now be board-certified in the field. As another indication of the growing prominence, the School of Medicine now has a fellowship in palliative care, with multiple training sites, including the Palo Alto Veterans Administration, home hospice and Stanford Hospital.

While many patients receive extensive and aggressive hospital care in the last six months of life, staff in the palliative care program say that patients often don’t have an understanding of how aggressive interventions will affect their quality of life and longevity, and they aren’t aware of palliative-care alternatives to major medical interventions.

“Our physicians have expertise in pain and symptom management, so it’s not about denying care,” Passaglia explained. “It is offering a different form of treatment.”

It meant all the difference to Georgia Sue Huston and her family. “We went from everyone doing all these tests, from aggressively treating her, to her saying, ‘I don’t want to do this anymore,’” her daughter said.

Heldebrant added that several of her nurse friends joined her in caring for her mother at home, taking time to bathe her, give her pain medications, and make her comfortable. “Everyone came to her birthday, and mostly she and I had time to talk,” she said. “The whole end-of-life care was just so exquisite for my mom.”

Source
Stanford Hospital & Clinics

In a study to be presented at the Society for Maternal-Fetal Medicine’s (SMFM) annual meeting, The Pregnancy Meeting™ in Chicago, researchers unveiled findings that demonstrate a link between the birth defect gastroschisis and the agricultural chemical atrazine.

Gastroschisis is a type of inherited congenital abdominal wall defect in which the intestines, and sometimes other organs, develop outside the fetal abdomen through an opening in the abdominal wall. The incidence of gastroschisis is on the rise, increasing two to four times in the last 30 years.

Researchers at the University of Washington (Seattle), were alerted to a higher than normal number of cases in Eastern Washington which caused them to hypothesize that the increased incidence could be due to environmental exposures in that area.

“Our state has about two times the national average number of cases of gastroschisis,” said Dr. Sarah Waller, one of the study’s authors. “The life expectancy for fetuses with this diagnosis is better than 90 percent; however it requires delivery at a tertiary care center with immediate neonatal intervention which often separates families and can cause serious financial and emotional stress.”

The team conducted a study of all cases of live born infants with gastroschisis during the period of 1987-2006. They matched birth certificates with U.S. Geological Survey databases of agricultural spraying. They looked at the chemicals atrazine, nitrates, and 2,4-dichlorophenoxyacetic acid.

Of the 805 cases and 3616 controls in the study, gastroschisis occurred more frequently among infants whose mothers resided less than 25 km from the site of high surface water contamination with atrazine. No risk was associated with the other chemicals reviewed in the study. The risk of gastroschisis also increased for women who conceived in the spring (March through May), when chemical use is more prevalent.

The study was authored by Sarah Waller, M.D., Kathleen Paul, M.D., Suzanne Peterson, M.D., and Jane Hitti, M.D., of the University of Washington, Seattle.

Source:
Vicki Bendure
Society for Maternal-Fetal Medicine

In a study presented at the Society for Maternal-Fetal Medicine’s (SMFM) annual meeting, The Pregnancy Meeting™ in Chicago, researchers unveiled findings that show that it is not cost effective to screen for spinal muscular atrophy.

Spinal muscular atrophy (SMA) is the most common genetic cause of infant mortality and the second most common inherited autosomal recessive disorder. There is controversy about whether prenatal carrier detection should be routinely offered to couples. In the November 2008 issue of the Genetics in Medicine Journal, the American College of Medical Genetics recommended that carrier screening for SMA should be made available to all families. However, the American College of Obstetricians and Gynecologists, in a committee opinion from May 2009, recommended against preconception and prenatal screening in the general population.

In the study presented at the Society for Maternal-Fetal Medicine’s meeting, researchers describe the analytic model that was created to compare a policy of universal prenatal SMA screening to that of no screening. Baseline assumptions included a disease prevalence of 1 in 10,000 for a carrier rate of 1 in 50 with 70% of affected children having severe disease. They assumed a 90% sensitivity rate for carrier screening and that 2% of SMA cases arise from de novo mutations. Baseline cost estimates (2009 dollars) included $400 for a carrier screen and $260,000 for the lifetime cost of a child with severe disease. Maternal quality-adjusted life-years (QALYs) were calculated assuming a 22% reduction in quality of life for having a child with severe disease and 8% for fetal loss.

The results showed that 11,000 women would have to be screened to prevent one case of SMA, at a cost of 4.7 million dollars per case averted.

“Our findings show that screening everyone for SMA is not cost effective,” said one of the study’s authors, Dr. Sarah Little of Massachusetts General Hospital. “Our results, however, were most sensitive to changes in the baseline prevalence of disease, suggesting that prenatal SMA screening may be cost effective in high risk populations, such as those with a family history of disease.”

Source:
Vicki Bendure
Society for Maternal-Fetal Medicine

Researchers at the University of Copenhagen have become the first in the world to synthesize the entire protein that is responsible for life-threatening malaria in pregnant women and their unborn children. The protein known as VAR2CSA enables malaria parasites to accumulate in the placenta and can therefore potentially be used as the main component in a vaccine to trigger antibodies that protect pregnant women against malaria. The research team is now planning to test the efficacy of the protein-based vaccine on humans.

The hope is that within 10 years all African girls could be vaccinated against
maternal malaria, thereby preventing more than 200,000 deaths a year.

Each year, 25 million pregnant women in sub-Saharan Africa run the risk of
contracting malaria. Women who have become infected with malaria parasites
during their first pregnancy are at considerable risk of severe anaemia and
significant impairment of foetal growth. The malaria parasites accumulate in the placenta, resulting in children being born prematurely and underweight. These women are also at greater risk of dying during pregnancy and childbirth. Maternal malaria is the cause of death of between 100,000 and 200,000 newborn babies and 10,000 women each year.

“The malaria research group discovered the protein VAR2CSA, which is
responsible for malaria parasite binding in the placenta, in 2003,” says Associate Professor Ali Salanti from the centre. “The aim is to produce a vaccine based on VAR2CSA which elicits antibodies that stop the parasite from binding to the placenta. The challenge for us has been to produce the entire protein in the laboratory, as it is very large and so technically complex. Now that we’ve managed to do this, we’re a big step closer to developing a human vaccine, as we can already test it as a vaccine in animals.”

“In collaboration with scientists at The Tanzanian National Institute for Medical Research, we’ve tested the antibodies that were produced in the laboratory on a number of malaria parasites from pregnant women in Tanzania,” says Professor Thor Theander from the centre. “These antibodies seem to be effective at preventing the parasite from accumulating in the placental tissue. The next step is to investigate whether we can elicit the same antibodies and so protect against the disease by vaccinating humans. Then the vaccine will be a reality.”

The Centre for Medical Parasitology (CMP) at the Department of International Health, Immunology and Microbiology, University of Copenhagen is an international leader in malaria research. With more than 70 employees, the centre is one of the largest malaria research units in the world and a leader in the development of vaccines. The centre’s work is partly funded by Danish and international foundations, including the Gates Foundation.

The discovery is presented in the latest issue of the Journal of Molecular Biology J Mol Biol. 2010 Jan 25. [Epub ahead of print], Press release ID: 20109466

Source:
Sandra Szivos
University of Copenhagen

Children from urban areas whose mothers suffer from depression during pregnancy are more likely than others to show antisocial behavior, including violent behavior, later in life. Furthermore, women who are aggressive and disruptive in their own teen years are more likely to become depressed in pregnancy, so that the moms’ history predicts their own children’s antisocial behavior.

That’s the conclusion of a new longitudinal study conducted by researchers at Cardiff University, King’s College London, and the University of Bristol. The research appears in the January/February 2010 issue of the journal Child Development.

The study considered the role of mothers’ depression during pregnancy by looking at 120 British youth from inner-city areas. “Much attention has been given to the effects of postnatal depression on young infants,” notes Dale F. Hay, professor of psychology at Cardiff University in Wales, who worked on the study, “but depression during pregnancy may also affect the unborn child.” The youths’ mothers were interviewed while they were pregnant, after they gave birth, and when their children were 4, 11, and 16 years old.

The study found that mothers who became depressed when pregnant were four times as likely to have children who were violent at 16. This was true for both boys and girls. The mothers’ depression, in turn, was predicted by their own aggressive and disruptive behavior as teens.

The link between depression in pregnancy and the children’s violence couldn’t be explained by other factors in the families’ environments, such as social class, ethnicity, or family structure; the mothers’ age, education, marital status, or IQ; or depression at other times in the children’s lives.

“Although it’s not yet clear exactly how depression in pregnancy might set infants on a pathway toward increased antisocial behavior, our findings suggest that women with a history of conduct problems who become depressed in pregnancy may be in special need of support,” according to Hay.

Source:
Sarah Hutcheon
Society for Research in Child Development

Focus on the Family plans to air a second television advertisement four times during the Super Bowl pregame show that will also feature former University of Florida quarterback Tim Tebow and his mother, Pam Tebow, USA Today reports (Horovitz, USA Today, 2/5).

The organization is sponsoring a yet-to-be-seen in-game commercial featuring the Tebows discussing Pam’s personal story of contracting amoebic dysentery while pregnant with Tim and ignoring doctors’ recommendations to have an abortion ( Women’s Health Policy Report, 2/1). According to Focus on the Family CEO Jim Daly, the original advertisement was rejected after CBS executives said that Pam Tebow’s line, “Both of our lives were at risk,” was “too much” (USA Today, 2/5).

Opposition Continues

The Tebow spot has “been the subject of one of the most intense tugs-of-war over an ad in many years,” with abortion-rights supporters and opponents both up in arms, the New York Times reports. In response to the Tebow ad, Planned Parenthood Federation of America released its own online ad featuring Olympic gold medalist Al Joyner and former NFL player Sean James supporting a woman’s right to make her own “decision about her health and her family” (Elliott, New York Times, 2/5).

The New York-based Women’s Media Center — which is leading a coalition of abortion-rights organizations — has called on CBS to pull the ad. On Wednesday, Women’s Media Center urged supporters to call NFL Commissioner Roger Goodell. According to Women’s Media Center President Jehmu Greene, the ad “has no place in the biggest national sports event of the year — an event meant to bring people together” (Kadaba, Philadelphia Inquirer, 2/5).

Editorials, Opinion Pieces Comment on Ad

~ Los Angeles Times: Women’s Media Center’s call for CBS to cancel the Tebow ad is “a shame, and CBS is to be congratulated for standing up to the pressure,” a Los Angeles Times editorial states. “We’re solidly for abortion rights, but the campaign against the ad is a misguided attempt at censorship,” according to the editorial. It adds that CBS’ recent reconsideration of its policy on advocacy ads is “a sensible move,” as long as “the network applies this policy fairly to groups across the political spectrum” (Los Angeles Times, 2/5).

~ Katha Pollitt, The Nation: “[P]art of me was thrilled to learn that Focus on the Family was paying” $2.5 million on a thirty-second Super Bowl ad because “[e]very dollar [the group] spends messaging the fans is a dollar not available to pay the electricity bill or keep staff on payroll,” Pollitt, an author, writes in an opinion piece. She says it is “maddening that the people who want to take away women’s right to choose have annexed ‘choice’ to their own cause,” noting that if the law required women to continue troubled pregnancies “there would be no heroism in doing so.” Pollitt continues, “In retrospect it was probably a mistake for pro-choice and feminist organizations to demand that CBS cancel the ad.” However, the “trouble is, much of the abortion-rights case is about averting damage, and it’s harder to tell those stories,” she says (Pollitt, The Nation, 2/4).

~ Lisa Miller, Newsweek: The controversy over the Tebow ad is “a case in point” of how “Americans like values, but they don’t know which values they like best,” Newsweek religion editor Miller writes in an opinion piece. She also questions how abortion-related ads are different from product ads, saying, “What’s the difference … between ‘selling’ an ideology on TV and selling a hamburger?” According to Miller, “In a working democracy, with a capitalist economy and protected free speech, there is none.” She writes, “Isn’t promoting one idea over another the foundation of free debate — and, more crassly, the business of advertising?” (Miller, Newsweek, 2/4).

Reprinted with kind permission from nationalpartnership. You can view the entire Daily Women’s Health Policy Report, search the archives, or sign up for email delivery here. The Daily Women’s Health Policy Report is a free service of the National Partnership for Women & Families, published by The Advisory Board Company.

© 2010 The Advisory Board Company. All rights reserved.

Gene variants in a woman and her fetus can make them more susceptible to an inflammatory response to infections inside the uterus, which can increase the risk for a preterm birth, according to a study presented at a meeting of the Society for Maternal-Fetal Medicine, Reuters reports. Preterm delivery is a leading cause of infant mortality and disability, according to Reuters.

For the study, researchers in Chile analyzed 190 genes and more than 700 DNA variants from 229 women and 179 preterm infants — those born before 37 weeks’ gestation. The genetic material of the preterm group was compared with that of 600 women who delivered at full term. Lead researcher Roberto Romero of NIH said, “What we found was there were some DNA variants in the fetus that were associated with the occurrence of premature labor and delivery, and there were some genes in the mother that also increase the risk of premature labor and delivery.”

For the infants, the largest gene influence was the interleukin 6 receptor, which is related to the body’s response to inflammation. For women, researchers looked at a gene that affects structures in the cervix and uterus that dissolve at the beginning of labor. According to Romero, if an infection develops, the combination of these two genetic variants raises the risk of preterm labor as the body tries to preserve the health of the woman and fetus. Romero said this suggests that preterm delivery is an evolutionary mechanism designed to protect the woman and fetus.

Infants born preterm face a 120 times greater risk of death than infants born at full term. They are more likely than full-term infants to develop breathing difficulties, bleeding into the brain and neurological handicaps. About 500,000 U.S. infants and more than 13 million infants worldwide are born preterm annually, according to Reuters (Steenhuysen, Reuters, 2/4).

Reprinted with kind permission from nationalpartnership. You can view the entire Daily Women’s Health Policy Report, search the archives, or sign up for email delivery here. The Daily Women’s Health Policy Report is a free service of the National Partnership for Women & Families, published by The Advisory Board Company.

© 2010 The Advisory Board Company. All rights reserved.

In a study presented at the Society for Maternal-Fetal Medicine’s (SMFM) annual meeting, The Pregnancy Meeting™ in Chicago, researchers unveiled findings that show that there is an increased risk of intrauterine fetal death (IUFD), commonly known as stillbirth, in women who have fibroids.

IUFD, or still birth, is rare and affects only six to seven out of every thousand births.

The study, conducted by researchers at Washington University in St. Louis, Mo., identified women who had fibroids detected during their routine second trimester ultrasound for anatomic survey at 16-22 weeks.

“Fibroids are very common,” said Dr. Molly J. Stout, one of the study’s authors. “We think they occur in 5% to 20% of all women, but most women are asymptomatic and don’t even know they have them.”

The study was a retrospective cohort study of 64,047 women. Data were extracted on maternal sociodemographics, medical history, and obstetric outcomes. Pregnancies with any fetal anomalies were excluded. Women with at least one fibroid detected at the time of fetal anatomic survey were compared to women without fibroids. The primary outcome was IUFD after 20 weeks gestation. Univariate and multiple logistic regression analyses were used to estimate the risk of IUFD in women with fibroids, and subgroup was conducted by presence or absence of fetal growth restriction (IUGR).

The study found that of 64,047 women, the incidence of fibroids was 3.2% (n=2,058). The incidence of IUFD was significantly higher in the fibroid group than in the no-fibroid group (1.6% v. 0.7%, aOR 1.8, 95%CI 1.3-2.7) even after adjusting for factors including black race, tobacco exposure, chronic hypertension, and pregestational diabetes. In subgroup analysis, the risk relationship between fibroids and IUFD only persisted within the IUGR subgroup.

“Our results showed that women with a combination of fibroids and fetal growth restriction were at two-and-a-half times the risk of having a stillbirth, though the absolute risk remained rare,” said Dr. Alison G. Cahill, another of the study’s authors. “This may lead to a future recommendation for serial growth scans to monitor fetal growth in women with fibroids.”

Source:
Vicki Bendure
Society for Maternal-Fetal Medicine

President Obama, Secretary of State Hillary Rodham Clinton and other policymakers and religious leaders on Thursday spoke at the National Prayer Breakfast about various issues involving faith and politics, the Washington Post reports. During his remarks, Obama discussed the “erosion of civility” in Washington politics, saying, “Those of us in Washington are not serving the people as well as we should.” He added, “At times, it seems like we’re unable to listen to one another, to have at once a serious and civil debate” (Fletcher, Washington Post, 2/5).

Obama also denounced a controversial anti-homosexuality bill currently under consideration in the Ugandan legislature. He said that it is “unconscionable to target gays or lesbians for who they are,” adding that the bill is “odious” (CNN [1], 2/4). According to MSNBC’s “The Rachel Maddow Show,” Clinton also criticized the bill during her remarks, saying that religion “is used as a club to deny the human rights of girls and women from the Gulf to Africa to Asia, and to discriminate — even advocating the execution of gays and lesbians” (Maddow, “The Rachel Maddow Show,” MSNBC, 2/4). CNN reports that Clinton also expressed a personal preference for adoption over abortion and told the audience a story of opening a home for children born as a result of unintended pregnancies (CNN [2], 2/4).

During an appearance on Maddow’s show, Bishop Gene Robinson said that he is “so glad” that Obama and Clinton “took this opportunity to highlight” the issues involved with the Ugandan legislation. He said that lesbian women “are almost routinely raped in order to cure them of their homosexuality” (“The Rachel Maddow Show,” MSNBC, 2/4).

Former University of Florida football player Tim Tebow, who has been in the spotlight over an antiabortion-rights Super Bowl commercial for Focus on the Family, delivered the closing prayer at the event (CNN [2], 2/4).

Reprinted with kind permission from nationalpartnership. You can view the entire Daily Women’s Health Policy Report, search the archives, or sign up for email delivery here. The Daily Women’s Health Policy Report is a free service of the National Partnership for Women & Families, published by The Advisory Board Company.

© 2010 The Advisory Board Company. All rights reserved.

Researchers at Yale School of Medicine believe they may have discovered how the hormone progesterone acts to prevent preterm birth.

The findings were presented at the Annual Scientific Meeting of the Society for Maternal-Fetal Medicine (SMFM) in Chicago by Errol Norwitz, M.D., professor in the Department of Obstetrics, Gynecology & Reproductive Sciences at Yale.

Preterm birth – delivery prior to 37 weeks gestation – has become increasingly common over the past 40 years. Currently, one in eight pregnancies in the U.S. are delivered prematurely. These premature infants are at least seven times more likely to die or have long-term neurologic injury compared with infants delivered at term. Efforts to date to prevent preterm birth have been largely unsuccessful. Several recent studies have suggested that progesterone supplementation from weeks 16-20 of gestation through 36 weeks may prevent preterm birth in about one-third of high-risk women, but the molecular mechanism by which progesterone acts was not known until now.

One-third of preterm birth is linked to premature rupture of the fetal membranes. Prior studies have suggested that rupture results from weakening of the membranes by apoptosis (programmed cell death). Norwitz and his Yale colleagues have shown for the first time that progesterone can prevent apoptosis in fetal membranes.

“We were able to demonstrate that progesterone prevents apoptosis in an artificial environment in the laboratory in which we stimulated healthy fetal membranes with pro-inflammatory mediators,” said Norwitz. “Interestingly, and somewhat unexpectedly, we also saw an inhibition of apoptosis under basal conditions without the presence of pro-inflammatory mediators. This suggests that the same mechanism may also be important for the normal onset of labor at term.”

Co-authors on the study include Yale researchers Guoyang Luo, M.D., Vikki M. Abrahams, Serkaiem Tadesse, Edmund F. Funai, M.D., and Eric J. Hodgson, M.D.

Source:
Karen N. Peart
Yale University