Epidemiology of Polymorphic Eruption of Pregnancy

Some of our assumptions about this condition have been mistaken.

An eruption occurring in the third trimester of pregnancy, primarily in primigravid women, was first described in 1979 and given the designation pruritic urticarial papules and plaques of pregnancy (PUPPP). Later investigation linked the syndrome to twin pregnancies and excessive weight gain. Several subsequent studies found greater frequency when the fetus was male, but one other study found greater frequency with female fetal sex. Researchers have suggested that all eruptions of pregnancy be categorized together as polymorphic eruption of pregnancy (PEP).

These authors performed a retrospective, case-control study of 200 pregnancies: 40 women with PEP and 4 matched healthy controls each. The researchers noted a number of factors that were statistically associated with PEP in univariate analysis, including primigravidas, multiple-gestation pregnancy, maternal weight gain, male fetal sex, cesarean delivery, and hospitalization. In multivariate analysis, however, only male fetal sex, cesarean delivery, and hospitalization remained statistically significant. The authors did not have the data to analyze the risk for recurrence in these patients.

Comment: PUPPP or PEP does not occur only in primigravid women; it does not always occur in the third trimester of pregnancy and does not appear to be related to maternal weight gain. This condition appears to be more frequent in pregnancies with male fetuses and may yet prove to be related to multiple-gestation pregnancy. Patients with this disorder also have more-frequent cesarean delivery and more-frequent hospitalization. We wonder whether our standing belief that this disorder does not recur may soon be disproved.

— Jeffrey P. Callen, MD

Published in Journal Watch Dermatology February 8, 2008

Citation(s):
Regnier S et al. A case-control study of polymorphic eruption of pregnancy. J Am Acad Dermatol 2008 Jan; 58:63.

Glucose-Control Arm of ACCORD Trial Halted Early

Increased mortality associated with aggressive glucose reduction raises safety concerns.
The National Heart, Lung, and Blood Institute has announced the early termination of one treatment arm of the ongoing Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial because of an increased risk for death among patients assigned to intensive glucose-lowering therapy (press release, February 6, 2008). The 5128 participants (at 77 North American sites) randomized to treatment aimed at reducing HbA1c levels to <6.0% will now be treated to a target HbA1c level of 7.0% to 7.9%, the same as participants in the control group. Two concurrent trials of management strategies for cholesterol and hypertension will continue as planned.
The Data and Safety Monitoring Board of ACCORD recommended stopping intensive glucose-lowering therapy after it found that 257 patients in that group had died, compared with 203 in the standard therapy group: a difference of 3 per 1000 participants per year during a mean of about 4 years of treatment. Preliminary analyses have found no association of the mortality increase with any specific drug or drug combination. All participants in the ACCORD study have type 2 diabetes and either coronary heart disease or at least two risk factors for adverse cardiovascular events.
Comment: The ACCORD trial was inspired by previous research that found a link between tightly controlled blood sugar and reduced risk for many complications of type 2 diabetes. Why an increased risk for death was associated with tight glucose control in this trial remains unclear. These results raise questions about intensity of and appropriate targets for glucose-lowering treatment in patients with type 2 diabetes, but they do not alter current guidelines or treatment strategies for most diabetic patients.
— Joel M. Gore, MD
Published in Journal Watch Cardiology February 13, 2008

Best Strategies for Urinary and Fecal incontinence

Complete Review Annals of Internal Medicine

The best approaches to treating and preventing adult incontinence are the subject of two articles released early by Annals of Internal Medicine.

One article, an examination of published evidence concerning nonsurgical treatment of urinary incontinence in women, reaches the following conclusions:

Pelvic floor muscle training would resolve 490 cases of stress incontinence per 1000 cases treated.
Oral hormonal therapy increased rates of incontinence, and estrogens administered transdermally or vaginally produced inconsistent improvements.
Oxybutynin and tolterodine increased continence rates, but duloxetine was not better than placebo.
Adrenergic drugs (clenbuterol, norepinephrine, and phenylpropanolamine) were not effective.
The other article, a "state-of-the-science" statement on adult incontinence from an NIH-sponsored conference, concludes:

"Routine episiotomy is the most easily preventable risk factor for fecal incontinence."
Pelvic floor muscle training may "prevent or reduce urinary incontinence in older women and in men undergoing prostate surgery," while lifestyle changes, such as weight loss and exercise, may prevent both urinary and fecal incontinence