Day: 03/14/2022

Maternal cannabis use during pregnancy and maternal and neonatal outcomes: A retrospective cohort study

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Abstract

Objective

To examine the relationship between reported prenatal cannabis use and neonatal and maternal outcomes and whether the legalisation of cannabis in Canada affected the rates of reported use or the association with maternal and neonatal outcomes.

Design

Population-based retrospective cohort study.

Setting

Routinely collected data in a real-world setting.

Population

All women in the Canadian province of Nova Scotia with singleton births between 1 January 2004 and 30 June 2021.

Methods

The association between cannabis use and maternal and neonatal outcomes was examined using generalised linear models with inverse probability weighting.

Main outcome measures

Maternal and neonatal outcomes in the peripartum and postpartum period.

Results

Rates of reported cannabis use in pregnancy increased from 1.3% to 7.5% over the study period with no appreciable change in slope after legalisation in 2018. Infants of mothers reporting cannabis use in pregnancy were more likely to have major anomalies and a 5-minute Apgar score ≤7, require neonatal intensive care unit admission, and had lower birthweight, head circumference and birth length than infants of mothers not reporting cannabis use. These associations did not differ before and after legalisation.

Conclusions

Reported cannabis use during pregnancy is associated with early postnatal complications and reduced fetal growth, even after taking into account a range of confounding factors. Rates of reported cannabis use during pregnancy increased over the past 5 years in Nova Scotia with no apparent additional effect of legalisation.

Source: BJOG

Maternal liver dysfunction in early pregnancy predisposes to gestational diabetes mellitus independent of preconception overweight: A prospective cohort study

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Abstract

Objective

To evaluate whether the associations of maternal liver dysfunction and liver function biomarkers (LFBs) with gestational diabetes mellitus (GDM) are independent of overweight.

Design

Prospective cohort study.

Methods

A sub-cohort of pregnant women with seven LFBs examined at 9–13 weeks of gestation and with complete GDM evaluation at mid-gestation were extracted from the prospective Shanghai Preconception Cohort Study. Associations of liver dysfunction, defined as having any elevated LFB levels, and individual LFB levels with GDM incidence were assessed by adjusting body mass index and other covariates in the multivariable logistic regression model. Odds ratios (ORs) and 95% CI were reported.

Main outcome measures

Incident GDM.

Results

Among 6211 pregnant women, 975 (15.7%) developed GDM. Liver dysfunction was associated with increased odds of GDM (OR 1.63; 95% CI 1.38–1.92). This association persisted after adjustment for BMI (adjusted OR [aOR] 1.37; 95% CI 1.15–1.63). Higher γ-glutamyl transferase, alanine aminotransferase, alkaline phosphatase, and albumin levels were also linked with GDM (aOR per 1 SD: 1.15, 95% CI 1.08–1.23; 1.10, 1.03–1.17; 1.21, 1.13–1.29 and 1.19, 1.11–1.27, respectively). Similar magnitudes of associations were observed between normal weight and overweight pregnant women.

Conclusion

Maternal liver dysfunction in early pregnancy predisposes women to subsequent GDM, and this association is independent of being overweight preconception. Our findings of an increased risk even in normal-weight pregnant women adds new mechanistic insights about the pathophysiological role of liver function in GDM aetiology.

Source: BJOG

Do Women Need More Sleep Than Men?

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Why Do Women Need More Sleep Than Men?

There are a number of reasons why women may need more sleep than men. Women are 40 percent more likely2 to have insomnia than men. Women are also nearly twice as likely to suffer from anxiety3 and depression4 as men, two conditions strongly associated with insomnia5. Individuals with insomnia have difficulty falling or staying asleep on a regular basis, and suffer from sleepiness during the day.

Hormones are another culprit behind women’s greater need for sleep than men. Our sleep-wake cycles6 are ruled by our hormones. These hormones affect when we feel tired, when we feel alert, when we feel hungry, and much more. Women experience hormonal changes each month and over the course of their lifetimes, which impact their circadian rhythms7 and create a greater need for sleep. For example:

  • During menstruation, one-third of women have trouble sleeping due to cramps, headaches, and bloating. They report higher levels of daytime sleepiness, tiredness, and fatigue8.
  • During pregnancy, women may develop restless legs syndrome, a condition that makes it harder to fall asleep. They’re also more likely to experience depression, sleep apnea, pain, and incontinence which disrupt their sleep. These sleep issues can persist into the postpartum9 period, when their hormone levels drop at the same time they start taking care of a newborn with an irregular sleep cycle — often resulting in even more daytime sleepiness.
  • During menopause, up to 85 percent of women experience hot flashes10. When these occur at night, women wake up in a sweat, thereby disrupting their sleep. Women’s risk of developing sleep apnea also increases during menopause11. This sleep disorder causes pauses in breathing that can interfere with the quality of one’s sleep, even if the person doesn’t wake up. As a result, women with sleep apnea may feel less refreshed upon waking up and experience tiredness and excessive sleepiness during the day.

Do Women Actually Sleep More Than Men?

While research tells us that women need more sleep than men, it’s also the case that women tend to sleep slightly longer than men — by just over 11 minutes.

The bad news, however, is that women’s sleep may be lower quality than men’s, perhaps due to differences in how they spend their day. Researchers have documented differences in the amount of time women and men dedicate to paid and unpaid labor, work and social responsibilities, and family caregiving12. For example, women are more likely than men to wake up to take care of others in the home, a task which disrupts their sleep.

Both men and women with children enjoy slightly more sleep than their childless counterparts, independent of marital status. However, women are more likely to nap13 during the day, which suggests their longer total sleep time may be misleading, since some of it takes place during the day. Naps add to a person’s total sleep time, but they also make nighttime sleep less restful.

Sleep works best when you sleep uninterrupted throughout the night. During a full night’s sleep, you cycle through the various stages of sleep several times a night — from light sleep to deep sleep to REM sleep and back again. With each subsequent stage of sleep, you spend more time in REM sleep, a time for dreaming and cognitive processing, and less time in deep sleep, a time where your body physically repairs itself. When that sleep is interrupted, you start the cycle over again — causing you to miss out on essential REM sleep.

Multiple studies have found that women fall asleep faster14  than men. This may suggest they have a greater need for sleep; it could also suggest they are simply more tired on average. Studies show women also spend more time in deep sleep15 than men. Although that changes in menopause, when women take longer to fall asleep and spend less time in deep sleep than men.

Do You Need More Sleep?

Regardless of which gender needs more sleep, the reality is too many women and men don’t get enough sleep, no matter their age. According to the CDC, only 64.5 percent of men and 65.2 percent of women actually sleep at least 7 hours per night16 on a regular basis. The numbers are even worse among high school students, especially young women. 71.3 percent of female students regularly miss out on good sleep, compared with only 66.4 percent of their male counterparts.

The best way to know if you’re getting enough sleep is whether you feel refreshed and restored when you wake up. If you’re having trouble sleeping, try getting regular exercise, setting routine bed and wake times, limiting your caffeine and alcohol intake, and improving your sleep environment. Develop a bedtime routine that calms down your mind and body before sleep. If your insomnia persists, talk to your doctor to determine other steps you can take to improve your sleep.

Sleep Hygiene

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What it is, why it matters, and how to revamp your habits to get better nightly sleep

Our medical review team has recently evaluated this page to ensure accuracy. We will continue to monitor and revise this article as new literature is published on sleep hygiene.

Paying attention to sleep hygiene is one of the most straightforward ways that you can set yourself up for better sleep.

Strong sleep hygiene means having both a bedroom environment and daily routines that promote consistent, uninterrupted sleep. Keeping a stable sleep schedule, making your bedroom comfortable and free of disruptions, following a relaxing pre-bed routine, and building healthy habits during the day can all contribute to ideal sleep hygiene.

Every sleeper can tailor their sleep hygiene practices to suit their needs. In the process, you can harness positive habits to make it easier to sleep soundly throughout the night and wake up well-rested.

Why Is Sleep Hygiene Important?

Obtaining healthy sleep is important for both physical and mental health, improving productivity and overall quality of life. Everyone, from children to older adults, can benefit from better sleep, and sleep hygiene can play a key part in achieving that goal.

Research has demonstrated that forming good habits is a central part of health1. Crafting sustainable and beneficial routines makes healthy behaviors feel almost automatic, creating an ongoing process of positive reinforcement. On the flip side, bad habits can become engrained even as they cause negative consequences.

Thankfully, humans have an impressive ability2 to make our habits serve our long-term interests. Building an environment and set of routines that promote our goals can really pay off.

Sleep hygiene encompasses both environment and habits, and it can pave the way for higher-quality sleep and better overall health.

Improving sleep hygiene has little cost and virtually no risk, making it an important part of a public health strategy3 to counteract the serious problems of insufficient sleep and insomnia in America.

What Are Signs of Poor Sleep Hygiene?

Having a hard time falling asleep, experiencing frequent sleep disturbances, and suffering daytime sleepiness are the most telling signs of poor sleep hygiene. An overall lack of consistency in sleep quantity or quality can also be a symptom of poor sleep hygiene.

How Do You Practice Good Sleep Hygiene?

Good sleep hygiene is all about putting yourself in the best position to sleep well each and every night.

Optimizing your sleep schedule, pre-bed routine, and daily routines is part of harnessing habits to make quality sleep feel more automatic. At the same time, creating a pleasant bedroom environment can be an invitation to relax and doze off.

A handful of tips can help in each of these areas, they aren’t rigid requirements. You can adapt them to fit your circumstances and create your own sleep hygiene checklist to help get the best sleep possible.

Set Your Sleep Schedule

Having a set schedule normalizes sleep as an essential part of your day and gets your brain and body accustomed to getting the full amount of sleep that you need.

  • Have a Fixed Wake-Up Time: Regardless of whether it’s a weekday or weekend, try to wake up at the same time since a fluctuating schedule keeps you from getting into a rhythm of consistent sleep.
  • Prioritize Sleep: It might be tempting to skip sleep in order to work, study, socialize, or exercise, but it’s vital to treat sleep as a priority. Calculate a target bedtime based on your fixed wake-up time and do your best to be ready for bed around that time each night.
  • Make Gradual Adjustments: If you want to shift your sleep times, don’t try to do it all in one fell swoop because that can throw your schedule out of whack. Instead, make small, step-by-step adjustments of up to an hour or two4 so that you can get adjusted and settle into a new schedule.

Don’t Overdo It With Naps: Naps can be a handy way to regain energy during the day, but they can throw off sleep at night. To avoid this, try to keep naps relatively short and limited to the early afternoon.

Follow a Nightly Routine

How you prepare for bed can determine how easily you’ll be able to fall asleep. A pre-sleep playbook including some of these tips can put you at ease and make it easier to get to fall asleep when you want to.

  • Keep Your Routine Consistent: Following the same steps each night, including things like putting on your pajamas and brushing your teeth, can reinforce in your mind that it’s bedtime.
  • Budget 30 Minutes For Winding Down: Take advantage of whatever puts you in a state of calm such as soft music, light stretching, reading, and/or relaxation exercises.
  • Dim Your Lights: Try to keep away from bright lights because they can hinder the production of melatonin, a hormone that the body creates to facilitate sleep.
  • Unplug From Electronics: Build in a 30-60 minute pre-bed buffer time that is device-free. Cell phones, tablets, and laptops cause mental stimulation that is hard to shut off and also generate blue light that may decrease melatonin production.
  • Test Methods of Relaxation: Instead of making falling asleep your goal, it’s often easier to focus on relaxation. Meditation, mindfulness, paced breathing, and other relaxation techniques can put you in the right mindset for bed.
  • Don’t Toss and Turn: It helps to have a healthy mental connection between being in bed and actually being asleep. For that reason, if after 20 minutes you haven’t gotten to sleep, get up and stretch, read, or do something else calming in low light before trying to fall asleep again.

Cultivate Healthy Daily Habits

It’s not just bedtime habits that play a part in getting good sleep. Incorporating positive routines during the day can support your circadian rhythm and limit sleep disruptions.

  • Get Daylight Exposure: Light, especially sunlight, is one of the key drivers of circadian rhythms that can encourage quality sleep.
  • Be Physically Active: Regular exercise can make it easier to sleep at night and also delivers a host of other health benefits.
  • Don’t Smoke: Nicotine stimulates the body in ways that disrupt sleep, which helps explain why smoking is correlated with numerous sleeping problems5.
  • Reduce Alcohol Consumption: Alcohol may make it easier to fall asleep, but the effect wears off, disrupting sleep later in the night. As a result, it’s best to moderate alcohol consumption and avoid it later in the evening.
  • Cut Down on Caffeine in the Afternoon and Evening: Because it’s a stimulant, caffeine can keep you wired even when you want to rest, so try to avoid it later in the day. Also be aware if you’re consuming lots of caffeine to try to make up for lack of sleep.
  • Don’t Dine Late: Eating dinner late, especially if it’s a big, heavy, or spicy meal, can mean you’re still digesting when it’s time for bed. In general, any food or snacks before bed should be on the lighter side.
  • Restrict In-Bed Activity: To build a link in your mind between sleep and being in bed, it’s best to only use your bed only for sleep with sex being the one exception.

Optimize Your Bedroom

A central component of sleep hygiene beyond just habits is your sleep environment. To fall asleep more easily, you want your bedroom to emanate tranquility.

While what makes a bedroom inviting can vary from one person to the next, these tips may help make it calm and free of disruptions:

  • Have a Comfortable Mattress and Pillow: Your sleeping surface is critical to comfort and pain-free sleep, so choose the best mattress and best pillow for your needs wisely.
  • Use Excellent Bedding: The sheets and blankets are the first thing you touch when you get into bed, so it’s beneficial to make sure they match your needs and preferences.
  • Set a Cool Yet Comfortable Temperature: Fine-tune your bedroom temperature to suit your preferences, but err on the cooler side (around 65 degrees fahrenheit).
  • Block Out Light: Use heavy curtains or an eye mask to prevent light from interrupting your sleep.
  • Drown Out Noise: Ear plugs can stop noise from keeping you awake, and if you don’t find them comfortable, you can try a white noise machine or even a fan to drown out bothersome sounds.
  • Try Calming Scents: Light smells, such as lavender6, may induce a calmer state of mind and help cultivate a positive space for sleep.

Is Sleep Hygiene the Same For Everyone?

The basic concept of sleep hygiene — that your environment and habits can be optimized for better sleep — applies to just about everyone, but what ideal sleep hygiene looks like can vary based on the person.

For that reason, it’s worth testing out different adjustments to find out what helps your sleep the most. You don’t have to change everything at once; small steps can move you toward better sleep hygiene.

It’s also important to know that improving sleep hygiene won’t always resolve sleeping problems. People who have serious insomnia or sleep disorders like obstructive sleep apnea may benefit from better sleep hygiene, but other treatments are usually necessary as well.

In other words, even though it may be beneficial, sleep hygiene alone isn’t a panacea. If you have long-lasting or severe sleeping problems or daytime sleepiness, it’s best to talk with a doctor who can recommend the most appropriate course of treatment.

Postpartum thoughts of infant-related harm, OCD unrelated to risk of maternal aggression

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Postpartum unwanted intrusive thoughts based on intentional infant-related harm or obsessive-compulsive disorder were not associated with elevated risk of harm to infants, according to a study published in the Journal of Clinical Psychiatry.

“UITs of infant-related harm are a core feature of postpartum OCD,” Nichole Fairbrother, PhD, assistant professor of psychiatry at the University of British Columbia, and colleagues wrote.

Sad Woman with Sad Baby

“Further, although it is widely accepted that OCD is not associated with an increased risk of violence and that sufferers are not at risk of acting on the content of their obsessions, this assertion has not been formally assessed.”

Researchers sought to evaluate the connection between new mothers’ UITs of intentional harm and OCD with maternal aggression toward their infants, and to document the prevalence of the same.

It is estimated that 1 in 4 American children suffer from some form of maltreatment, the authors note. Referrals to child protective services suggest a prevalence rate of 9 per 1,000 cases.

The study drew from a prospective, province-wide sample of 763 English-speaking women who had just given birth and were aged 19 years and older. A total of 388 participants responded. Study enrollees completed two questionnaires and interviews postpartum to gauge incidence of UITs of infant-related harm, OCD (based on DSM-5 criteria), and maternal aggression toward their infant. Data were collected from February 2014 to February 2017.

Fairbrother and colleagues found 2.9% (95% CI, 1.5% to 4.7%) of participants (n = 11) reported non-ideated aggressive behavior toward their child. The estimated prevalence of experiencing UITs within the first 9 months postpartum was 44.4% (95% CI, 32.9% to 49.7%).

Mothers who reported UITs of intentional, infant-related harm were not more likely to report aggression toward their newborn compared with women who did not report this ideation. The same held true for women with and without OCD.

“The findings from this study provide critical and reassuring information regarding the relation between new mothers’ UITs of intentional harm and the risk of violence toward the infant,” the researchers wrote.

COVID-19 disruptions led to steep declines in dengue cases

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Disruptions related to the COVID-19 pandemic led to steep declines in cases of dengue in endemic regions, with more than 723,000 cases averted in 2020, researchers reported in Lancet Infectious Diseases.

Oliver J. Brady, DPhil, associate professor and fellow at the London School of Hygiene & Tropical Medicine, and colleagues pooled data on monthly dengue incidence from WHO weekly reports, climatic data and population variables for 23 countries — 16 in Latin America and seven in Southeast Asia — from 2014 to 2019. The 23 countries reported at least 2,000 cases of dengue per year.

Source: Adobe Stock.

The researchers compared model predictions with reported 2020 dengue data and assessed whether there were differences in projected incidence from March 2020 through the end of the year. They observed differences following pandemic measures, such as lockdowns and social distancing.

Nineteen of the 23 countries reported a lower dengue incidence in 2020 compared with the average incidence rates from 2014 to 2019. Compared with 2019, there was a 44.1% decrease in incidence across all areas of the study — 2.28 million cases in 2020 compared with 4.08 million cases in 2019.

Specifically, in Latin America, there was a 40.2% decrease in cases — 569.26 per 100,000 cases in 2019 to 340.33 per 100,000 in 2020. Likewise, in Southeast Asia, there was a 58.4% decrease — 297.31 per 100,000 cases in 2019 to 123.58 per 100,000 in 2020.

“Before this study, we didn’t know whether COVID-19 disruption could increase or decrease the global burden of dengue,” Brady said in a statement. “While we could assume reduction in human movement would reduce the virus transmission, it would also disrupt the mosquito control measures already in place. This disruption may result in long-term impacts on dengue cases, which might not be evident until the next epidemic.”

According to the authors, the decrease in cases was even more pronounced among the 19 countries beginning in April 2020, following the implementation of COVID-19 mitigation strategies. Nine countries experienced complete suppression of the 2020 dengue season, the authors wrote, whereas most other countries experienced highly suppressed seasons.

“These abnormal declines coincide with the introduction of public health and social measures and the subsequent shift of human movement behaviors toward time spent in residential premises in late March to April,” the authors wrote.

Assessing other potential variables, the researchers reported that the climate in 2020 was similar to the average climate in the previous 6 years. There was also no evidence that the decline in cases was due to underreporting.

The authors compared observed and predicted dengue cases between April and December 2020 and estimated that there were 0.72 million (95% CI, 0.12-1.47) fewer dengue cases— a 35% (95% CI, 9-56) decrease potentially attributed to pandemic-related disruptions.

School closures represented 70.95% (95% CI, 55.55-80.48) of the reduction in cases, and reductions in movement in nonresidential locations accounted for 30.95% (95% CI, 15.57-43.65), the researchers said.

“Currently dengue control efforts are focused on or around the households of people who get sick,” Brady said. “We now know that, in some countries, we should also be focusing measures on the locations they recently visited to reduce dengue transmission. For all the harm it has caused, this pandemic has given us an opportunity to inform new interventions and targeting strategies to prevent dengue.”

Paclitaxel plus carboplatin ’preferred regimen of choice’ for gynecologic carcinosarcomas

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Paclitaxel plus carboplatin demonstrated noninferiority to paclitaxel plus ifosfamide and should be a standard treatment for uterine carcinosarcoma, according to results of a phase 3 study published in Journal of Clinical Oncology.

“The better tolerated and more convenient regimen of paclitaxel-carboplatin should be the preferred regimen of choice for gynecologic carcinosarcomas,” Matthew A. Powell, MD, professor of obstetrics and gynecology and chief in the division of and chief gynecologic oncology at Washington University School of Medicine in St. Louis, told Healio.

Survival outcomes among women.
Powell MA, et al. J Clin Oncol. 2022;doi:10.1200/JCO.21.02050.

Background

An estimated 66,570 women in the U.S. received a diagnosis of uterine cancer and another 21,410 received a diagnosis of ovarian cancer in 2021, according to study background. A regimen of paclitaxel and carboplatin has been the standard for epithelial ovarian carcinoma for decades and became the standard for endometrial carcinomas within the last 2 years.

Previous studies showed benefits of the paclitaxel-ifosfamide regimen, but the treatment has drawbacks, according to Powell.

Matthew A. Powell, MD

Matthew A. Powell

“The ifosfamide regimen (is associated with) significant toxicity in this often-frail population (and) the 3-day regimen is also very inconvenient for patients and requires growth factor support,” he told Healio. “Also, we learned that molecularly, these cancers are epithelial tumors and not true sarcomas, so perhaps the paclitaxel-carboplatin regimen would be superior.”

Methodology

Powell and colleagues tested the null hypothesis that paclitaxel-carboplatin was inferior to paclitaxel-ifosfamide in an international, open-label study that included 449 adult women with uterine carcinosarcoma. Nearly half (47.9%) had stage III or stage IV disease at enrollment.

Researchers randomly assigned 228 of the women to paclitaxel-carboplatin (median age, 65 years; 65.8% white; 28.9% Black) and 221 to paclitaxel-ifosfamide (median age, 64 years; 60.2% white; 32.6% Black), administered in 3-week cycles for six to 10 cycles.

OS from the date of randomization served as the study’s primary endpoint, with PFS, adverse events, quality of life and neurotoxicity scores as secondary endpoints.

Key findings

Paclitaxel plus carboplatin demonstrated noninferiority to paclitaxel plus ifosfamide. Results showed median OS of 37 months with paclitaxel-carboplatin vs. 29 months with paclitaxel-ifosfamide (HR = 0.87; 90% CI, 0.7-1.07) and median PFS of 16 months vs. 12 months (HR = 0.735; 95% CI, 0.58-0.93).

Researchers observed similar toxicities between the groups, with more hematologic toxicities in the paclitaxel-carboplatin group and more confusion and genitourinary hemorrhaging in the paclitaxel-ifosfamide group.

Among a separate cohort of 90 women with ovarian carcinosarcoma, researchers reported longer OS (30 months vs. 25 months) and PFS (15 months vs. 10 months) with paclitaxel and carboplatin, but the differences did not reach statistical significance.

Implications

The findings establish paclitaxel plus carboplatin as a new standard regimen for uterine carcinosarcomas of all stages, especially among women with stage III disease, researchers wrote. Future areas of study included identifying and targeting molecular aberrations within the tumors, which should lead to further improvements in treatment, they concluded.

High alcohol consumption, smoking linked to neurodegeneration, MS risk in UK adults

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High alcohol use was associated with more severe neurodegeneration and smoking was linked with greater probability of MS diagnosis, according to a U.K. study published in JAMA Network Open.

“Both genetic and environmental factors are known to play important roles in the pathophysiology of MS,” Iris Kleerekooper, PhD, of Queen Square MS Centre and the department of neuroinflammation at University College London Institute of Neurology, and colleagues wrote. “Understanding the role of modifiable risk factors, such as smoking, alcohol intake and obesity, is important to guide clinical counseling.”

alcohol bottles with silhouetted man

Kleerekooper and colleagues investigated these risk factors by analyzing data from of 71,981 individuals, aged 40 to 69 years, from the community-based UK Biobank study on health behaviors and retinal thickness. Of those, 20,065 were healthy controls, 51,737 had comorbidities and 179 had MS.

Participants completed a questionnaire on health-related behaviors, demographics and socioeconomic data, and researchers used multivariable generalized estimating equations to determine whether alcohol use and smoking were linked with macular ganglion cell layer and inner plexiform layer (mGCIPL) thickness. They also examined whether those correlations differed for MS patients.

Results demonstrated that smoking, moderate alcohol consumption and obesity were significantly associated with MS case status compared with healthy control individuals. High alcohol intake was associated with a thinner mGCIPL in MS patients (P = .02). In the alcohol interaction model, researchers found that high alcohol intake was associated with thinner mGCIPL in control individuals (P < .001); however, there was no statistically significant association in individuals with MS. Data also revealed that smoking was not associated with mGCIPL thickness in MS patients but was associated with increased mGCIPL thickness in the control group (P < .001).

“The presented findings suggest that current recommendations for the general population regarding smoking and moderating alcohol consumption may be particularly relevant for individuals who have been diagnosed with MS or who are at risk for the disease,” Kleerekooper and colleagues wrote.

“Popeye deformity” associated with proximal biceps tendon rupture

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A 70-year-old man presented to our clinic with suddenonset pain and abnormal bulging in his right upper arm. He was a farmer, and reported engaging in strenuous overhead activity, but did not remember any trauma. He had a history of chronic intermittent shoulder pain and a previous diagnosis of tendinitis. On examination, we observed that the belly of the patient’s biceps appeared to bulge more distally on the right than the left (Figure 1). Hand supination was painful and weaker on the right side than the left. We diagnosed rupture of the proximal tendon of the long head of the biceps brachii.

Figure 1:

Figure 1:

Photographs of a 70-year-old man with biceps tendon rupture. (A) Bilateral comparison with elbow flexion shows hump formation on the right side caused by bulging of the biceps muscle because of proximal rupture, compared with the intact biceps on the contralateral side. Panels (B) and (C) show close-up photographs of the bulging right and normal left biceps muscles, respectively.

The “Popeye sign” observed in our patient is pathognomonic for this condition. We confirmed the diagnosis with magnetic resonance imaging (MRI) of the shoulder, which showed no tendon within the bicipital groove (Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.210948/tab-related-content). We prescribed analgesia with nonsteroidal anti-inflammatory medication, and advised rest and activity modification. We also referred him to physiotherapy for range of motion optimization and strengthening of the rotator cuff and scapular stabilizers.1 At 2-month follow-up, the patient reported occasional arm cramping that did not restrict his activities. He had full range of motion of the shoulder, with a residual bulge formation when he flexed his elbow. Supination was no longer painful and showed no weakness.

Complete proximal biceps tendon rupture occurs more often in older men, usually spontaneously because of tendon degeneration. 1 Its incidence is unknown, but risk factors include smoking, older age, repetitive overhead activities, chronic tendinitis and steroid use or injection.2 It can occur secondary to degeneration and is not always preceded by trauma.

Diagnosis of proximal biceps tendon rupture is clinical and supported by a history of shoulder overuse, chronic tendinitis or rotator cuff disease. After conservative management, if pain and deformity are unresolved on follow-up, clinicians should investigate with ultrasonography or MRI and refer the patient to orthopedics to assess for tenodesis.2,3

References

  1. ↵
    1. Nho SJ, 
    2. Strauss EJ, 
    3. Lenart BA, 
    4. et al
    . Long head of the biceps tendinopathy: diagnosis and management. J Am Acad Orthop Surg 2010;18:645–56.PubMedGoogle Scholar
  2. ↵
    1. Elser F, 
    2. Braun S, 
    3. Dewing CB, 
    4. et al
    . Anatomy, function, injuries, and treatment of the long head of the biceps brachii tendon. Arthroscopy 2011;27:581–92.CrossRefPubMedGoogle Scholar
  3. ↵
    1. Vestermark GL, 
    2. Van Doren BA, 
    3. Connor PM, 
    4. et al
    . The prevalence of rotator cuff pathology in the setting of acute proximal biceps tendon rupture. J Shoulder Elbow Surg 2018;27:1258–62.Google Scholar

Diagnosis and management of postural orthostatic tachycardia syndrome

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EY POINTS

  • Postural orthostatic tachycardia syndrome (POTS) is a chronic multisystem disorder; the cardinal feature is orthostatic tachycardia.
  • Patients with POTS have symptoms of orthostatic intolerance that improve with recumbence.
  • Girls and women are more commonly affected with POTS, beginning in puberty and through early adulthood.
  • Postural orthostatic tachycardia syndrome can lead to marked functional disability, often limiting work or schooling.
  • Treatments for POTS can improve symptoms and function, and can be initiated in primary care.

The main characteristic of postural orthostatic tachycardia syndrome (POTS) is tachycardia when standing, without a drop in blood pressure. Patients describe lightheadedness and palpitations when upright, particularly when standing, which sometimes leads to syncope. Patients may experience impaired quality of life and functional disability, which can be economically devastating.1–3 The syndrome is more common in girls and young women and has been associated with other disorders, like migraine and Ehlers–Danlos syndrome.4 We discuss the diagnosis of POTS, conditions to consider in the differential diagnosis, associated disorders and the pharmacologic and nonpharmacologic management of patients with POTS, based on original research, narrative reviews and consensus statements.

Conclusion

Postural orthostatic tachycardia syndrome is a chronic, multi-system disorder involving the autonomic nervous system. The cardinal feature is symptomatic, exaggerated sinus tachycardia with upright posture. Girls and women are more commonly affected with POTS, starting around puberty and through early adulthood. Patients with POTS can experience functional disability, with a limited ability to work or go to school, and a decreased quality of life. Increased physician recognition and effective management has the potential to improve the lives of affected patients.