Medical Bulletin 14/ March/ 2024

According to a study published in the Journal The BMJ, cervical pessary may be less effective than vaginal progesterone in reducing adverse perinatal outcomes in women with a singleton pregnancy with no prior spontaneous preterm birth of less than 34 weeks’ gestation and with a cervical length of 25 mm or less.

Preterm birth is the most important problem in obstetric care and globally the most important cause of neonatal mortality, morbidity, and subsequent neurodevelopmental disorders. Progesterone is widely understood to reduce preterm birth in pregnant women with a short cervical length. A second potential preventive treatment is the use of a cervical pessary, which was reported to reduce preterm birth at less than 34 weeks in women with a singleton baby and a cervical length of less than 25 mm.

The Amsterdam UMC research team studied the optimal treatment for pregnant women with a cervical length shorter than 25 mm at the 20-week ultrasound. Eligible participants had a healthy singleton pregnancy and a cervical length of 35 mm or less between 18 and 22 weeks gestation. Those assigned to the pessary group received an Arabin25 cervical pessary, removed at 36 weeks. Participants in the progesterone group self-administered 200 mg vaginal progesterone capsules daily until 36 weeks. Data collection included maternal and obstetric history, pregnancy details, and neonatal outcomes, with follow-up until 10 weeks after the due date.

The results revealed that in women who had singleton births with no prior spontaneous preterm birth of less than 34 weeks’ gestation and with a mid-trimester cervical length of 35 mm or less, pessary did not improve perinatal outcome compared with progesterone. In the subgroup of a cervical length of 25 mm or less, differences seemed larger in favour of progesterone, especially for extremely preterm birth at less than 28 weeks.

"This is an important improvement that can contribute to the reduction of preterm births and the associated complications, such as an increased risk of infant mortality and long-term health problems for the child," said Eva Pajkrt, professor of obstetrics at Amsterdam UMC. "Based on our study, we recommend measuring the length of the cervix of all pregnant women during the 20-week ultrasound. Women with a cervix shorter than 25 mm should be informed about the possibility of treatment with Progesterone."

Reference: Charlotte E van Dijk, Annabelle L van Gils, Maud D van Zijl, Bouchra Koullali, Eline S van den Akker, Brenda J Hermsen, Wilhelmina M van Baal, Henricus Visser, Yolanda M de Mooij, Martijn A Oudijk, Ben WJ Mol, Brenda M Kazemier, Eva Pajkrt; Journal: The BMJ; DOI: 10.1136/bmj-2023-077033

Depression increases cardiovascular risk more in women than in men, finds study

According to a new study published in Journal of the American College of Cardiology, people with depression face an increased risk of cardiovascular disease (CVD); however, women experience higher CVD risk following a depression diagnosis than men.

Depression is the third leading cause of morbidity worldwide. Prior research showed that it is associated with a heightened risk of cardiovascular events, including myocardial infarction (MI), angina, stroke and CV mortality. Women with depression showed a greater relative risk of developing heart-related negative health outcomes than men. Although there is little research on the evidence of sex differences in the impact of depression on heart health.

“The identification of sex-specific factors in the adverse effects of depression on cardiovascular outcomes may help in the development of targeted prevention and treatment strategies that address the specific CVD risks faced by depressed patients,” said Hidehiro Kaneko, MD, assistant professor at the University of Tokyo in Japan and a corresponding author of the study. “A better understanding will allow healthcare providers to optimize care for both men and women with depression, leading to improved CVD outcomes for these populations.”

Researchers studied depression's connection to subsequent cardiovascular events in a cohort using the JMDC Claims Database from 2005 to 2022. They identified 4,125,720 participants meeting the criteria, with a median age of 44. Depression was diagnosed before the initial health checkup. The primary outcome included MI, angina, stroke, heart failure, and atrial fibrillation. Data collection involved BMI, blood pressure, and lab values. Statistical analysis compared clinical characteristics between participants with and without depression.

Results indicated that the hazard ratio of depression for CVD was 1.39 in men and 1.64 in women compared with participants without depression. Models also indicated that hazard ratios of depression for MI, angina, stroke, heart failure, and atrial fibrillation were higher for women than for men.

The study authors also highlighted that women may experience more severe and persistent symptoms, especially during hormonal changes like pregnancy or menopause. Additionally, women are more susceptible to traditional risk factors like hypertension, diabetes, and obesity when depressed, which can lead to cardiovascular disease.

“Our study found that the impact of sex differences on the association between depression and cardiovascular outcomes was consistent,” said Kaneko. “Healthcare professionals must recognize the important role of depression in the development of CVD and emphasize the importance of a comprehensive, patient-centered approach to its prevention and management. Assessing the risk of CVD in depressed patients and treating and preventing depression may lead to a decrease of CVD cases.”

References: Keitaro Senoo, Hidehiro Kaneko, Kensuke Ueno, Yuta Suzuki, Akira Okada, Katsuhito Fujiu, Taisuke Jo, Norifumi Takeda, Hiroyuki Morita, Kentaro Kamiya, Junya Ako, Koichi Node, Hideo Yasunaga, and Issei Komuro; Journal: Journal of the American College of Cardiology; DOI: 10.1016/j.jacasi.2023.11.015

Research reveals the mechanism by which chikungunya virus leads to mortality

A study published in the journal Cell Host & Microbe revealed that the chikungunya virus, responsible for more than 10 million cases recorded in around 125 countries over the past 20 years since its arrival, is capable of spreading through the blood, reaching multiple organs and crossing the blood-brain barrier, which protects the central nervous system.

The mechanism by which chikungunya virus can lead to death typically involves severe complications such as encephalitis, severe dehydration from persistent fever and vomiting, or exacerbation of underlying health conditions in individuals. While fatalities directly caused by chikungunya are rare, severe cases can result in systemic complications that contribute to mortality.

The study analyzed data from 32 deceased patients and included test results for the presence of CHIKV in the body, as well as laboratory and autopsy information. Histopathology, quantification of cytokines, metabolomics, proteomics and viral genomic analysis, as well as real-time reverse transcription-polymerase chain reaction were performed in samples of blood serum, cerebrospinal fluid and other tissues. The scientists also evaluated samples and tests from two other groups, one consisting of 39 survivors of acute CHIKV infection and the other consisting of 15 blood donors.

The results showed the presence of CHIKV in cerebrospinal fluid samples, indicating its ability to cross the blood-brain barrier, the physical layer that protects the central nervous system and normally prevents pathogens from entering.

The findings indicated that the invasion of chikungunya virus occurs through two mechanisms: first, the virus infects CD14+ and CD16+ monocytes and, in the presence of high levels of CCL-2 it migrates across the barrier and is transported to the brain; second, the infection affects proteins that are important for holding the epithelial cells of the blood-brain barrier together.

“This shows that CHIKV is not only responsible for arthralgia, which causes fever, muscle pain and joint swelling, but leads to neurological damage,” explained William Marciel de Souza, professor at the University of Kentucky (United States) and lead author of the study. “In the blood, we observed a severe alteration in the coagulation cascade, with a decrease in some key proteins, as well as hemodynamic damage in the organs, i.e. excess fluid. In the immune system, the levels of cytokines associated with inflammation were higher than those observed in chikungunya patients who survived.”

Reference: William M. de Souza, Marcilio J. Fumagalli, Shirlene T.S. de Lima, Pierina L. Parise, Deyse C.M. Carvalho, Cristian Hernandez, Ronaldo de Jesus, Jeany Delafiori, Darlan S. Candido, Victor C. Carregari, Stefanie P. Muraro, Gabriela F. Souza, Leda M. Simões Mello, Ingra M. Claro, Yamilka Día, Rodrigo B. Kato, Lucas N. Trentin, Clauber H.S. Costa, Ana Carolina B.M. Maximo, Karene F. Cavalcante,Scott C. Weaver; Journal: Cell Host & Microbe; DOI: 10.1016/j.chom.2024.02.011