Journals Watch: Assisted conception and vitamin D

A research review, this week covering assisted conception, vitamin D, blood pressure monitoring and COPD. By Dr Sally Hope

The decision to transfer one or two embryos should be based on age and other prognostic indicators (Photograph: SPL)
The decision to transfer one or two embryos should be based on age and other prognostic indicators (Photograph: SPL)

Age and embryo transfer in assisted conception
Lancet 2012; 379(9815): 521-7

Many years ago, one of my patients had triplets following IVF. So I was interested to read the conclusion of this study, that 'transfer of three or more embryos at any age should be avoided'.

This prospective study of UK Human Fertilisation and Embryology Authority data investigated whether perinatal live birth outcomes varied by the number of embryos transferred in relation to maternal age.

The ORs of live birth were higher in women aged ≥40 than in women who were younger when two embryos were transferred compared with one embryo (3.12), but the absolute difference in risk of live birth was smaller (0.09 for women aged ≥40 versus 0.156 for those aged <40; p <0.0001).

The conclusion is that the decision to transfer one or two embryos should be based on age and other prognostic indicators.

Vitamin D and health in postmenopausal women
Maturitas 2012; 71(1): 83-8

Recently vitamin D deficiency has been linked not only to osteomalacia, but also to cardiovascular disease, diabetes, cancer, infections and neurodegenerative disease. However, large prospective trials are lacking.

Vitamin D is produced by cutaneous synthesis using sunlight, from precursors derived from oily fish, eggs and milk. There is no international agreement on an optimal level of 25-hydroxy vitamin D, but proposed levels vary from 30-90ng/ml (75-225nmol/L). Levels vary in a given person depending on time of year (sun exposure), latitude, altitude, air pollution, skin pigmentation, diet, use of sunblock and clothing.

Risk factors for low vitamin D levels are malabsorption from any cause, malnutrition, lack of sunlight, medications (antiepileptics, antiretrovirals) and skin ageing.

Fortified foods are not enough to guarantee sufficient vitamin D. The European Menopause and Andropause Society advises 15 minutes of sun exposure three to four times a week without sunblock and supplementation of 600IU vitamin D, increasing to 800IU in people over 70.

Perhaps if we all start taking vitamin D supplements between October and April, our bones might age better.

Self-monitoring BP and self-titration of medication
Br J Gen Pract 2012; 62: e135-42

The NICE hypertension guidelines advocate 24-hour ambulatory recording or self-monitoring, so this paper on patients' experiences from the Telemonitoring and Self Management in the Control of Hypertension trial was timely.

In this trial, 527 patients with poorly controlled hypertension were randomised to usual care or telemonitoring with self-monitoring and self-titration of antihypertensive medication. The researchers interviewed 23 patients and six family members about self-monitoring and self-titration with telemonitoring.

All were positive about self-monitoring. There was no evidence they became obsessed with their BP readings, with potential harm (a previous objection to self-monitoring).

The patients developed a better understanding of the variability of BP over time, and confidence in interpreting readings. Most were less positive about instituting change themselves, despite training and protocols, and chose to consult their GP again before doing so, especially if the readings were borderline.

Self-monitoring is acceptable in some hypertensive patients, after training and support.

Consequences of COPD beyond its effect on the lungs
Clin Med 2012; 12(1): 71-4

This review reminds us of our holistic duties beyond the 'irreversible airflow limitation, associated with an abnormal inflammatory response, primarily caused by smoking'. COPD has profound extrapulmonary features, relevant to managing the patient.

Skeletal muscle weakness is a common complication. Weight-bearing muscles show fibre atrophy, with reduced strength and endurance, resulting from disuse, hypoxia, inflammation and steroid use.

Pulmonary rehabilitation programmes can increase functional capacity without changing lung function. Similarly, all of the above, plus cigarette smoke and a low vitamin D level, put COPD patients at high risk of osteoporosis, and with their muscle weakness, increase their risk of falls and fracture.

Smoking also puts them at high risk of cardiovascular disease; COPD patients have a 10-fold increased risk of MI and a 3.4-fold increased risk of stroke. COPD hyperinflation reduces cardiac filling and impairs cardiac output.

Peripheral neuropathy, mild cognitive impairment (from the hypoxia) can cause difficulties in concordance with understanding and remembering new treatments.

Depression is common, as is GORD (because of the flattened diaphragm impairing the gastro-oesophageal sphincter).

T'ai chi and postural stability in Parkinson's disease
N Engl J Med 2012; 366: 511-19

Regular slow exercise, such as t'ai chi, has been shown to be one of the few cost-effective interventions to reduce falls and fractures in the elderly.

This study randomly assigned patients with Parkinson's disease into three groups: t'ai chi, resistance training or stretching. Everyone had one hour of training, twice weekly for 24 weeks.

The t'ai chi group performed better than the other two in directional control and maximum excursion, and these measurements translated into a real functional improvement.There was a lower incidence of falls in the t'ai chi group compared with the stretching group. The improvement was maintained three months after the intervention stopped.

  • Dr Hope is a GP in Woodstock, Oxfordshire, and a member of our team who regularly review the journals

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

CPD IMPACT: EARN MORE CREDITS

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Audit how many IVF twins versus spontaneous twins patients at your practice have had in the past 10 years.
  • Consider running an evening session for interested patients on how to self-monitor BP.
  • Consider reviewing your COPD protocols and check that extrapulmonary matters, such as depression, muscular strength, assessment for osteoporosis and cardiovascular disease, are on your template.

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