Insights from outside BJOG

Citizens of the USA spend more on their health per person than other nations – over $9400 per annum (Papanicolas et al. JAMA 2018;319:1024–39). This figure compares with a range of $3400 to $6800 in the other 10 highest-earning nations in the world. It appears that that the greatest drivers of rising costs are administration, pharmaceuticals, hospitalisation, interventions, investigations and ‘generosity at the beginning and end of life’ (Parente JAMA 2018;319:988–90). Perhaps the most daunting task in addressing rising costs is the variation in standards of care, with excellent care for individuals who are economically advantaged but reduced facilities for those who are ‘out of the financial loop’. Nevertheless, 8% of gross domestic product (GDP) is spent on public health care, amounting to $1.5 trillion per year (Emanuel JAMA 2018;319:983–5). The USA spends in total more of its GDP (17.8%) than any other country. In a watershed publication, Papanicolas et al. describe how Americans spend heavily but their health system performs poorly in areas of healthcare coverage and health outcomes when contrasted with the mean results from the other top 10 high-income nations. For example, the USA has the lowest life expectancy (79 years versus a mean for all 11 countries of 82 years), the highest infant mortality (5.8 versus 3.6 per 1000 live births), maternal mortality (26 versus 8 per 100 000 live births) and caesarean rates (33% versus 25%). There are other outlier results for the USA: only 11% of the population aged 15 years or more are smokers versus the overall mean of 17%, and overall death rates have declined in the past three decades from 745 to 578 per 100 000 individuals, but 70% of adults are overweight or obese (versus the overall mean of 56%). The picture is mixed and real reform could only be brought about by a coordinated change in policy, which some commentators do not think likely with the current presidential administration (Bauchner and Fontanarosa JAMA 2018;319:990–2). Finally, it is sobering to learn that the greatest burden of disease in the USA is attributed to tobacco consumption, high body mass index, poor diet, alcohol and drug use, high fasting plasma glucose and high blood pressure (The US Burden of Disease Collaborators JAMA 2018;319:1444–72). With the current opioid crisis in the USA crying out for a preventive solution, much depends on lifestyle choices to improve the health of the nation (Peltz and Südhoff JAMA 2018;319:2071–2). The relationship between menopausal hormone therapy and cardiovascular health is controversial: studies have been published showing benefits and harms. Early observational research indicated that menopausal hormone replacement therapy (HRT) had a cardio-protective effect in women using it for menopausal symptoms and continuing to take it thereafter (Stampfer et al. NEJM 1991;325:756–62). There was, however, criticism that the women involved were a self-selected group with medical knowledge and healthy lifestyles. The Women's Health Initiative trial was randomised and used what were at the time standard medications, but the mean age of participating women was greater than 60 years, so the findings of cardiovascular harm were not unexpected (Writing Group for the Women's Health Initiative Investigators JAMA 2002;288:321–33). A subsequent evaluation of the continuing data has shown no difference in mortality rates between participants receiving HRT and placebo (Manson et al. JAMA 2017;318:927–38). It has been proposed that the commencement of HRT in relation to the menopause transition is important for cardiovascular outcomes – the timing hypothesis. It is not possible that future research will involve women well past their menopause initiating HRT, so studies will concern themselves with women who do and do not start taking HRT around the menopause transition. Such women can be followed up and the incidence of cardiovascular events recorded (with composite endpoints of mortality, heart failure and myocardial infarction) or they could have surrogate markers of cardiovascular health monitored such as biochemical serum levels, atherosclerotic progression as detected by cardiac computed tomography or coronary artery calcified-plaque burden. However, cardiovascular magnetic resonance (CMR) is the ‘most accurate and reproducible cardiac imaging modality’ that permits detection of subclinical changes in cardiac structure and function. A study using CMR from the UK has been published looking at cardiac parameters in postmenopausal women who have or have not been taking HRT (Sanghvi et al. PLoS One 2018;13:e0194015). Over 1500 healthy women who are part of the UK Biobank study were recruited to undergo CMR imaging looking at left ventricular and left atrial volumes and function, ‘alterations in which are markers of subclinical cardiovascular disease and have prognostic implications’. The cohort had a mean age of 51 years at their menopause transition. One-third had used HRT for a median duration of 8 years. Individuals using HRT had significantly better measures of cardiac function than nonusers, with a 2.4% lower left ventricular end-diastolic volume and a 4.5% higher left atrial maximal volume. The researchers conclude that HRT use ‘was not associated with adverse, subclinical changes in cardiac structure and function’. Women who are carriers of the BRCA1 mutation are at high risk of ovarian, breast and other cancers. Those who choose to be tested usually have a family history and, if found to be positive, face decisions about their reproductive planning and prophylactic operations such as a possible bilateral salpingo-oophorectomy (BSO) and mastectomies. Women choosing BSO in their thirties or forties are then confronted with a further choice: whether to embark on HRT. All the advantages of estrogens (and possibly progesterone) to gynaecological, biochemical, cardiovascular, dermatological and skeletal systems need to be weighed against any possible raised risk of breast cancer. Because such risk is unknown, a study was conducted in which more than 800 BRCA1 carriers who underwent BSO were followed up for 8 years for breast cancer and HRT use (Kotsopoulos et al. JAMA Oncol https://doi.org/10.1001/jamaoncol.2018.0211). Most participants were in their early 40s and all were disease-free at recruitment. During follow up, 11% were diagnosed with breast cancer, which is slightly less than the anticipated population numbers. Overall, HRT was not associated with breast cancer (hazard ratio 0.97, 95% CI 0.62–1.52). There was a difference between individuals taking estrogens alone and those who took estrogens plus progesterone, with the latter group having almost twice as many malignancies. The bottom line is that a BRCA1 mutation carrier who has a BSO can be reassured that estrogen-only replacement therapy will not increase her risk of breast cancer above that of noncarriers. Fish oil supplements are popular dietary additives that some people believe protect against heart disease. They are n−3 fatty acids (often called omega-3 fatty acids) and one in ten US citizens takes them, possibly because the American Heart Association (AHA) recommends that fish oil should be considered for patients who have had a recent heart attack. There is little to support such a view and even less for people with a balanced diet, which the AHA agrees should include fish twice a week. A meta-analysis (Aung et al. JAMA Cardiol 2018;3:225–34) looking at ten randomised trials involving 78 000 participants at high risk of cardiovascular disease did not show any benefits of marine-derived fatty acid supplements in terms of heart attacks, strokes, revascularisation procedures or mortality. As Abassi states, the outcome is ‘another nail in the coffin for fish oil supplements’ (JAMA 2018;319:1851–2). Many clinicians recommend the use of supplements of n−3 fatty acids orally to relieve the symptoms of dry eye disease. However, a recent placebo-controlled trial has shown that it is ineffective at a dose of 3 g over a year (The Dry Eye Assessment and Management Study Research Group NEJM 2018;378:1681–90). Caesarean delivery (CD) rates continue to climb, reaching 25% in Western Europe, 33% in North America and over 40% in South America. In high-income countries with sophisticated maternity services, the surgical, anaesthetic and short-term morbidity and mortality rates associated with CDs are low but by no means zero. In low- and middle-income countries such as South Africa, there are serious concerns about CD rate increases and maternal mortality (Gebhardt et al. S Afr Med J 2015;105:287–91). The long-term outcomes are important and an extensive systematic review and meta-analysis has been reported (Keag et al. PLoS Med 2018;15:e1002494). This is a big data investigation involving 30 million participants from high-income countries that honed in on specifics of maternal health, the wellbeing of children delivered by caesarean and pregnancies after CD. The researchers found benefits and harms when comparing CD with vaginal delivery. This report, published by the Guttmacher Institute, provides a global overview of the incidence of termination of pregnancy (TOP), laws regulating TOP and the safety of provision. Issues around unintended pregnancy and the impact of unintended pregnancy and TOP on women and couples are also investigated. Chapters cover current levels and recent trends, legality, methods of practice and how they have changed, consequences of clandestine TOP and unintended pregnancy. For the years 2010–14, the report estimates that 55.9 million TOPs occurred each year, with 49.3 million taking place in low-income regions and 6.6 million in high-income regions. It is noted that women who live in countries with the most restrictive laws have a TOP at around the same rate as women living in countries where it is more easily available. The highest estimated rates of TOP occur in Latin America and the Caribbean; the lowest rates are found in North America and Oceania. Figure 2.4 highlights the finding that the proportion of all TOP that are estimated to be least safe increases as laws become more restrictive, and Figure 3.1 illustrates that greater proportions of women in low-income regions than in high-income regions live under restrictive laws. Figure 3.3 focuses on countries that have changed categories within the legal continuum since 2000, all but one of which have broadened criteria for legal TOP. The report concludes that incidence of TOP and unintended pregnancy varies by geographic area and that access to safe TOP is improving but that in many countries unsafe TOP is still prevalent and restrictions on legal procedures are increasing. Service and policy recommendations are provided for circumstances where TOP is legal or highly restricted by law and for all settings. Available online at www.guttmacher.org The World Health Organization's (WHO) Department for Infectious Hazards Management has recently launched OpenWHO – a web-based platform offering online courses to improve responses to health emergencies. At the top right of the homepage, training is highlighted for outbreaks currently happening, offering quick and easy access to health professionals responding to immediate crises. Courses are arranged under four categories: outbreak, preparing for pandemics, ready for response and get social. The list can be filtered by language and proficiency level. Courses include risk communication for Zika virus, Ebola knowledge resources for responders, the Incident Management System, risk communication essentials, communication essentials for Member States, revised Cholera Kits and calculation tool, Pandemic Influenza Severity Assessment (PISA) and public health interventions in pandemics and epidemics. The web platform aims to provide both a global interactive learning network and a place for sharing expertise in public health and encouraging discussion on key issues in responding to health emergencies. The online courses are aimed at all professionals preparing to work in epidemics, pandemics or health emergencies, and those who are already working in such settings. The courses are self-paced and free-to-access. Available online at www.openwho.org This guide developed by WHO aims to standardise the language used for digital technologies for health to improve dialogue among different communities and stakeholders (public health professionals and technology-focused professionals) working in the arena. The standardisation was prompted by the need to synthesise evidence and research, conduct national inventories and landscape analyses, develop guidance resources to inform planning and articulate required digital functionality based on identified health system challenges and needs. Figure 1 provides an outline of linkages across health system challenges, digital health interventions and system categories. The classification categorises the different ways in which digital and mobile technologies are being used to support health and consists of interventions for clients, interventions for healthcare providers, interventions for health system or resource managers and interventions for data services. For each grouping, a separate more detailed list of synonyms and illustrative examples is provided. Available online at www.who.int This High Impact Practices brief, produced by the United States Agency for International Development (USAID), provides an overview of social and behavioural change interventions of relevance to programmes delivering family planning services. It states that inclusion of social and behavioural change programming can create a demand for, and improve the quality of, such services. The report discusses four high-impact practices relating to social and behavioural change: mass media, community group engagement, interpersonal communication and digital health. It also provides relevant examples, tips for implementation and a list of tools and resources. American College of Obstetricians and Gynecologists (ACOG) The following guideline is now available at www.acog.com Optimizing Postpartum Care (Committee Opinion), No. 736, May 2018 Faculty of Sexual and Reproductive Healthcare (FSRH) The following guideline is now available at www.fsrh.org FSRH launches plan of implementation for FSRH Vision in Scotland at Stakeholder Seminar Society of Obstetricians and Gynaecologists of Canada (SOGC) The following guideline is now available at www.jogc.com Induced Abortion: Surgical Abortion and Second Trimester Medical Methods This patent application discusses the use of a phosphodiesterase inhibitor, administered transvaginally, as an alternative to assisted reproductive techniques for infertile couples. Specifically, the inventors state that a phosphodiesterase inhibitor is administered transvaginally immediately before and/or after sex. Pardina Palleja MC, Vaz-Romero UMA. 30 April 2018. This patent application relates to the development of biodegradable contraceptive implants for women that consist of a biocompatible polyester copolymer composition and a delivery system that can administer effective doses of a contraceptive such as progestin. This application claims benefit of U.S. Provisional Application No. 62/411,872, filed 24 October, 2016. Saltzman W, Quijano E, Yang F, Jiang Zhaozhong, Owen D. 3 May 2018. This patent application outlines devices and methods for the intravaginal delivery of lubricants such as aqueous lubricants for the treatment of vaginal dryness in women. This application is a continuation of U.S. application Ser. No. 15/490,628 filed 18 April 2017, which is a continuation of U.S. application Ser. No. 14/987,306 filed 4 January 2016, which is a continuation of U.S. application Ser. No. 14/709,138 filed 11 May 2015, now U.S. Pat. No. 9,226,894, which is a continuation of U.S. application Ser. No. 13/884,936 filed 12 November 2013, now U.S. Pat. No. 9,078,813 which is a U.S. national phase application of International Application Serial No. PCT/US2011/060389, filed on 11 November 2011, which claims priority to U.S. Provisional Application No. 61/413,238 filed 12 November 2010, U.S. Provisional Application No. 61/516,582 filed 5 April 2011, and U.S. Provisional Application No. 61/542,552 filed 3 October, 2011. Kiser PF, McCabe RT, Kiser MN, Albright TH. 19 April 2018. This patent application relates to scaffolds to aid uterine tissue growth and help polarisation for in vitro fertilisation procedures. This application is based on U.S. Provisional Application No. 62/408,407, filed 14 October 2016. Barmat L, Falk M, Jain H, Somkuti S. 19 April 2018. The Governor of Arizona in the USA has recently passed a bill dictating how a couple's frozen embryos can be used in future if they become divorced or separated. The bill, which overrides any previous legal agreement between the couple, states that any frozen embryos previously created by a couple have to be given to the partner who wishes to use them to create a pregnancy, even if this contravenes the other partner's wishes. However, the bill also states that the partner who does not wish to create a child would have no legal responsibility to any resultant children. Source: www.bionews.org.uk A bill recently put forward to the Parliament in Malta reportedly aims to relax the country's current strict laws regarding assisted reproduction. The bill, if passed, will allow gamete donation and surrogacy, and would also allow single people and lesbian, gay, transgender and queer (LGBTQ) couples to access assisted reproduction services. Embryo research and embryo destruction, however, would remain illegal. Source: www.bionews.org.uk Clinicians keen to keep up-to-date regarding clinical studies that are currently recruiting may find the following informative.

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