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Preterm birth increases the risk of lifelong asthma and wheezing disorders

MD-FM Thursday January 30, 2014



Sarah : MD-FM: Medical News from around the world with Peter Goodwin


SEGMENT 1: PRETERM BIRTH: Children born pre-term are at increased risk of developing asthma and wheezing disorders 

PETER: Hello and with me is Sarah Maxwell. To begin with: premature babies are at increased risk of getting asthma or wheezing disorders –that’s what a study in PLoS Medicine suggests… and it’s a big concern because the number of babies born preterm and the number of prem. babies surviving are both increasing...

SARAH: Yes babies born before 37 weeks gestation were 50% more likely to develop asthma or a wheezing disorder compared to babies born at full term. And those born before 32 weeks of gestation had almost 3 times the risk! As well as this it seems that if symptoms appear, they don’t go away easily… Lead author Jasper Been:

BEEN: Previously it looked like, when children got older, they sort of grew over of their problems but, in our analysis, we show that the risks are the same for young children and for older children. And there’s more and more research coming out showing that, even, preterm birth gives you a higher risk of chronic lung problems in adulthood.

SARAH: That was Dr. Jasper Been, from the Maastricht University in the Netherlands. His group’s meta-analysis included over 1.5 million children. The mechanisms aren’t clear yet: a number of factors seem to be involved and it confirms that best environment for a foetus to develop is in the mother’s womb. Dr. Been’s conclusions:

BEEN: I think for doctors: the most important thing is to be aware of this because follow up of preterm babies now tends to focus on follow up of neurological problems, behavioural problems, learning problems... And I think the lungs deserve a place there. I think for moms it’s important to realize that there are certain things that increase the risk of preterm birth and asthma, and these include smoking and also overweight in moms.

SARAH: Jasper Been, from the Netherlands.


SEGMENT 2: For patients with early rheumatoid arthritis, reaching a stable low disease activity within six months is crucial 

PETER: For patients with early rheumatoid arthritis, reaching a stable low disease activity within six months of starting treatment gives a good long-term outcome, whatever the type of treatment you use.

SARAH: Yes, this is what a study published in The Lancet reported. And that was whether patients were treated with methotrexate alone or with methotrexate in combination with the anti-TNF biologic agent adalimumab.

DUREZ: The objective to obtain this slow disease activity or remission is crucial for every patient because we show that the response is correlated to the X-ray damage, if you do not respond you have more chances to have more destruction and less quality of life in the future.

SARAH: That was co-author Professor Patrick Durez, from Université Catholique de Louvain, in Brussels. Actually, a greater proportion of patients achieved this target when using the combination regimen, and in those successful patients, the biologic agent could even be withdrawn without affecting outcomes.

PETER: OK but biologics are expensive and they do have terrible side effects, so you’re certainly not going to start all your patients with RA on them… especially since there are other options to consider using with methotrexate before jumping on the biologics bandwagon

SARAH: Yes: glucocorticoids, of course. And that’s what Professor Durez recommends:

DUREZ: I think the first message is to obtain low disease activity or remission in these patients and, for this, you have to use an adapted dose of methotrexate, up to 20 mg a week, with corticosteroids or not, depending on the level of activity of inflammation in every patient, but it’s very important to induce this response with methotrexate in every patient. If you obtain the response, then after you can certainly decide to decrease the dose after 6 months.

SARAH: Depending on the remaining level of inflammation six months after beginning direct acting anti-rheumatoid therapy, a biologic may be considered

DUREZ: If you do not respond to methotrexate after 6 months, you have to inform the patient that an add-on treatment with anti-TNF therapy is probably the best choice to induce a more stable status and a low disease activity status after 6 months.

SARAH: That was Patrick Durez, from Brussels.

SEGMENT 3: Low dose aspirin associated with increased risk of gout attacks 

PETER: For patients with gout, taking low-dose aspirin was associated with an increased risk of recurrent gout attacks — these are the findings of a study in over 700 patients with gout, published in the Annals of Rheumatoid Diseases. Compared with no aspirin, the use of aspirin at doses below 325 mg/day, for two consecutive days, increased the adjusted odds ratio of attacks by 81%. But adding allopurinol cancelled the detrimental effects of aspirin.


SEGMENT 4: New pathway inhibitor shows promise in patients with indolent lymphoma refractory to standard alkylating chemotherapy and to rituximab 

PETER:  For patients who have indolent lymphoma that’s refractory to chemotherapy with standard alkylating agents and also to rituximab, a new chemotherapy-free regimen was found to be very effective and tolerable in a phase II study just published in the New England Journal of Medicine.  

SARAH: Yes there was an overall response rate of 57% in these doubly refractory patients who were treated with a continuous regimen of the oral agent Idelalisib — a new pathway inhibitor targeting the delta isoform of the P-I-3 kinase enzyme, which mediates several key biochemical pathways within malignant B-cells. The study’s principle author Ajay Gopal gave us the details:

GOPAL: Though we have many improved therapies now, inevitably these therapies eventually stop working and patients die of their disease. So there’s a desperate need… and so we were certainly very encouraged and 90 percent of patients had reductions in their lymph node size.

SARAH: The treatment was also safe:

GOPAL: This was actually very well tolerated, relative to other therapies. There was some transaminase elevation early on but in the vast majority of patients we just noted the lab abnormality and they continued taking the drug and it resolved on its own. There is some late diarrhoea in a minority of patients, after being on the drug for 6 to 12 months, which also can be treated either by pausing the drug or treating with anti-inflammatories. So I think the whole community is excited with this because we all have numbers of patients in our clinic really with very few options and with such a low toxicity oral therapy we are hopeful that this will provide meaningful benefit to them.

SARAH: That was Dr. Ajay Gopal, from the University of Washington in Seattle, speaking to us at the last meeting of the American Society of Hematology, where he presented his results.


SEGMENT 5: Early childhood bereavement contributes to future psychosis risk 

SARAH: Children who experience the death of a close family member are at increased risk of psychotic illnesses later in life…that’s according to Kathryn Abel, lead author of a study on this in the BMJ:

ABEL: Overall, in the early years of childhood, if the child is exposed to the loss of a nuclear family member –one of the parents or one of the other children –particularly if they are exposed between birth and the age of 3 years old, the child would have an increased risk, about two fold, following adjustments for everything, of developing a non-affective schizophrenia-like illness, and also of other psychotic disorders but mostly of that.

SARAH: The cause of death -accidental, illness, suicide --also influenced the risk:

ABEL: Following a suicide, so the most traumatic, if you like, we found that that risk was particularly high, again in the young children but particularly for subsequent affective disorders i.e. something like bipolar disorder. And this remained when we took into account suicide in the family or family history of psychiatric illness.

SARAH:  Professor Kathryn Abel, from the University of Manchester in the UK. Her team analysed data from a million children. So it seems that it’s not only a matter of genes... Environmental effects also have an impact on the development of mental illnesses.  Importantly, their data showed that maternal bereavement stress before or during pregnancy was not associated with psychosis in the offspring.

ABEL: It may well be that it’s changed their stress responses to become greater –they are less “cushioned” from other effects that may happen in childhood, they may be less protected, there may be less of a social network that’s around them, etc etc.

SARAH: Professor Kathryn Abel, from Manchester.


IN BRIEF 1: Exposure to pesticide DTT is a strong environmental risk factor for Alzheimer’s disease 

PETER: Finally, in brief: Dichloro-diphenyl-dichloro-ethylene (or DDE) — that’s the metabolite from the commonly-used pesticide DDT — is a strong environmental risk factor for Alzheimer’s disease. These are the conclusions of a case control study published in JAMA Neurology, which showed that patients with Alzheimer's disease had significantly higher blood levels of DDE compared to healthy people: about 4 times higher.


IN BRIEF 2: Psoriasis increases the risk of developing type-2-diabetes 

PETER: More research suggests that patients with psoriasis are at increased risk of developing type-2-diabetes: This is from a cohort study of over 6,600 patients with psoriasis, published in Diabetes Care. The authors found that the risk was modulated by the severity of psoriasis  (the more severe the skin disease the stronger the risk), the presence of comorbidities, and the use of medication.

PETER: That's all from MDFM for now. Sarah Maxwell and I will be back with more next week, so until then, from me Peter Goodwin, goodbye!



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Best of Science in Nutrition 2013: Yogurt for a healthier diet (EB & IUNS 2013)
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