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13 June 2018  |  Volume 5  |  Issue 12

Each bi-weekly issue of Current UpDate highlights a few of the recent, important additions to our "What's New" and "Practice Changing UpDates" topics.

This issue features “What’s New” entries related to:
  • Calcium and vitamin D supplementation for prevention of fractures in community-dwelling adults
  • Endovenous ablation for superficial reflux associated with venous ulceration
  • Maternal subclinical hypothyroidism and neurodevelopment in children

To see "What's New" in your specialty (and 25 others, including drug therapy), or to read "Practice Changing UpDates" across all specialties, click here.

 
Calcium and vitamin D supplementation for prevention of fractures in community-dwelling adults
 
Evidence supporting the benefit of calcium and vitamin D supplementation for fracture prevention is variable, likely due to differences in study design. In a United States Preventive Services Task Force (USPSTF) systematic review of 11 trials comparing vitamin D, calcium, or both with placebo or control in over 50,000 community-dwelling adults ≥50 years of age, vitamin D supplementation reduced the incidence of total fracture but not hip fracture [1]. Supplementation with vitamin D and calcium had no effect on incidence of total or hip fracture. The USPSTF recommends against daily supplementation with 400 IU or less of vitamin D and 1000 mg or less of calcium for the primary prevention of fractures in community-dwelling, postmenopausal women, and concluded there was insufficient evidence to assess the benefits and harms at higher doses [2]. For bone health, we encourage adequate nutrition (protein, calcium, and vitamin D) and weight bearing exercise in all adults. For older adults with inadequate dietary calcium and vitamin D intake, we suggest supplementation with 800 IU vitamin D and elemental calcium to achieve a total daily intake of 1200 mg (diet plus supplement).
1.Kahwati LC, Weber RP, Pan H, et al. Vitamin D, Calcium, or Combined Supplementation for the Primary Prevention of Fractures in Community-Dwelling Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force.JAMA 2018; 319:1600.

 

2. US Preventive Services Task Force,Grossman DC, Curry SJ, et al. Vitamin D, Calcium, or Combined Supplementation for the Primary Prevention of Fractures in Community-Dwelling Adults: US Preventive Services Task Force Recommendation Statement.JAMA 2018; 319:1592.

 

 
 
 
 
 
Endovenous ablation for superficial reflux associated with venous ulceration
 
Most patients with chronic venous ulcers have some degree of superficial vein reflux. Whether early ablation of superficial reflux alters outcomes is debated. A multicenter trial randomly assigned 450 patients with venous leg ulcers and proven superficial vein reflux to compression therapy plus early endovenous ablation within two weeks or compression therapy alone, with ablation at six months if the ulcer remained unhealed [3]. Early ablation resulted in a shorter median time to healing and a greater likelihood of healed ulcers at one year (94 versus 86 percent) but no differences in quality-of-life measures. Given the risks associated with endovenous ablation and only a modest improvement in ulcer healing, we continue to suggest conservative measures (leg elevation, exercise, and compression therapy) rather than more aggressive interventions for initial therapy.
3.Gohel MS,Heatley F,Liu X, et al. A Randomized Trial of Early Endovenous Ablation in Venous Ulceration.NEngl J Med 2018; 378:2105.

 

 
 
 
 
Maternal subclinical hypothyroidism and childhood neurodevelopmental outcomes
 
Several observational studies have suggested an association between maternal subclinical hypothyroidism (elevated thyroid-stimulating hormone [TSH], normal free thyroxine [T4]) during pregnancy and neuropsychological impairment in children. A new prospective cohort study in over 4500 mother-child pairs did not find an association between maternal subclinical hypothyroidism in early pregnancy (median TSH 3.22 mU/L) and childhood performance on National Curriculum Tests administered from ages 4 to 15 years [4]. The different outcomes in these studies may be related to differences in the degree of TSH elevation, maternal iodine status, and cognitive tests performed. The decision to treat subclinical hypothyroidism depends upon the degree of TSH elevation, and in some cases, the presence of thyroid peroxidase (TPO) antibodies.
4. Nelson SM,Haig C,McConnachie A, et al. Maternal thyroid function and child educational attainment: prospective cohort study.BMJ 2018; 360:k452.

 

 
 
 
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