Patients with intraoral and oral-cutaneous wounds commonly present to emergency departments (EDs), usually after sustaining blunt facial trauma. Many of these wounds are minor, small (<1 cm), hemostatic on presentation, and confined to the oral mucosa, requiring no specific intervention. Some of these injuries, however, do require wound repair, in particular large mucosal wounds (1 to 2 cm) and those that communicate with the overlying facial skin (``through-and-through`` wounds). Most emergency medicine textbooks consider these larger wounds to be at significant risk for infection because of oral bacterial flora and thus recommend that a course of prophylactic antibiotics be prescribed when primary repair of these wounds is performed in the ED, in addition to routine oral and local wound care. However, studies have shown that other wounds commonly considered to be at significant risk for secondary infection, such as simple lacerations of the hand, do not appear to conclusively benefit from prophylactic antibiotic therapy when careful wound preparation is performed before primary repair. We therefore reviewed the available literature to determine the strength of evidence supporting the use of prophylactic oral antibiotics for intraoral wounds treated and repaired in the ED.
 
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Objective The objective of this study was to examine whether the use of nicotine replacement therapy (NRT) during pregnancy increases the risk of stillbirth. Design Cohort study with prospective data. Setting Denmark 1996-2002. Population A total of 87 032 singleton pregnancies enrolled in the Danish National Birth Cohort for which information on NRT use as well as smoking was available. Methods Outcome of pregnancy was identified by register linkage, with <1% loss to follow up. We conducted Cox regression analyses to estimate the hazard ratio (HR) and 95% CI of stillbirth according to the use of NRT, type of NRT use and a combination of NRT use and smoking. Main outcome measures Stillbirth, defined as delivery of a dead fetus after 20 completed weeks of gestation. Results A total of 495 pregnancies (5.7 in 1000 births) ended in stillbirth, 8 of which were among NRT users (4.2 in 1000 births). After adjustment for confounders, women who used NRT during pregnancy had a HR of 0.57 (95% CI 0.28-1.16) for stillbirth compared with those who did not use NRT. Smoking during pregnancy was associated with an increased risk of stillbirth (HR 1.46, 95% CI 1.17-1.82), while women who both smoked and used NRT had a HR of 0.83 (95% CI 0.34-2.00) compared with nonsmoking women who did not use NRT. Conclusion Our study does not indicate that use of NRT during pregnancy increases the risk of stillbirth.
 
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Several recent prospective studies have reported that obesity is associated with an increased risk for chronic kidney disease (CKD), but it is unknown whether weight gain increases the risk for CKD if one remains within the ``normal`` category of body mass index (BMI). We prospectively followed a cohort of 8792 healthy men who had no known risk factors for CKD and participated in a comprehensive health evaluation program at a large worksite. During 35,927 person-years of follow-up, 427 new incident cases of CKD (estimated GFR <64 ml/min per 1.73 m(2)) developed. Cox proportional hazards modeling revealed that in both the normal-weight and overweight groups, a U-shaped association between weight change categories and development of CKD was observed after adjustment for age, baseline GFR, baseline BMI, HDL, fasting blood glucose, uric acid, and exercise habits. The lowest risk for CKD was observed among those whose weight changed -0.25 to <0.25 kg/yr (P < 0.001 for quadratic term). Weight change as a time-dependent variable was significantly related to CKD incidence. These relationships remained significant even after further adjustment for Homeostasis Model Assessment of Insulin Resistance, high-sensitivity C-reactive protein, systolic BP, diastolic BP, metabolic syndrome, incident hypertension, or incident diabetes. In summary, increases in body weight are independently associated with an increased risk for CKD, even when the BMI remains within the normal range.
 
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BACKGROUND: Identifying early pre-teen predictors of adolescent weight gain and the development of impaired fasting glucose (IFG) and type 2 diabetes (T2DM) at age 18-19 y could provide avenues for prevention. OBJECTIVE: We evaluated possible pre-teen predictors for development of IFG, T2DM, and changes in body mass index at age 18-19 y in black and white girls. DESIGN: In a prospective cohort study, body habitus and fasting insulin and glucose were measured at ages 9-10 and 18-19 y, and multiple 3-d diet records were collected. Factors predicting 10-y change in body mass index and development of IFG and T2DM together were assessed. RESULTS: In multivariate analyses, 10-y change in homeostatic model assessment of insulin resistance (HOMA-IR) and the age 9-10 y HOMA-IR x percentage of calories from fat interaction were positive predictors of 10-y changes in body mass index. At age 18-19 y, there were 5 incident cases of T2DM, 37 cases of IFG, and 597 noncases. Age 9-10 y IFG and HOMA-IR (or insulin), 10-y change in HOMA-IR (or insulin), and the age 9-10 y insulin x total caloric intake interaction predicted IFG and T2DM at age 18-19 y. CONCLUSIONS: Pre-teen IFG, insulin resistance (and insulin), and rapidly increasing insulin resistance during adolescence identifies girls who are at greater risk of future IFG and T2DM. In addition, insulin resistance, interacting with high-fat diets, identifies girls who are at risk of greater weight gain. These findings could open avenues to primary prevention of obesity, IFG, and T2DM in children.
 
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The authors assessed the effect of psychological stress on total and cause-specific mortality among men and women. In 1981-1983, the 12,128 Danish participants in the Copenhagen City Heart Study were asked two questions on stress intensity and frequency and were followed in a nationwide registry until 2004, with <0.1% loss to follow-up. Sex differences were found in the relations between stress and mortality (p = 0.02). After adjustments, men with high stress versus low stress had higher all-cause mortality (hazard ratio (HR) = 1.32, 95% confidence interval (CI): 1.15, 1.52). This finding was most pronounced for deaths due to respiratory diseases (high vs. low stress: HR = 1.79, 95% CI: 1.10, 2.91), external causes (HR = 3.07, 95% CI: 1.65, 5.71), and suicide (HR = 5.91, 95% CI: 2.47, 14.16). High stress was related to a 2.59 (95% CI: 1.20, 5.61) higher risk of ischemic heart disease mortality for younger, but not older, men. In general, the effects of stress were most pronounced among younger and healthier men. No associations were found between stress and mortality among women, except among younger women with high stress, who experienced lower cancer mortality (HR = 0.51, 95% CI: 0.28, 0.92). Future preventive strategies may be targeted toward stress as a risk factor for premature death among middle-aged, presumably healthy men.
 
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OBJECTIVES: To assess the effectiveness of a community-based falls-and-fracture nurse coordinator and multifactorial intervention in reducing falls in older people. DESIGN: Randomized, controlled trial. SETTING: Screening for previous falls in family practice followed by community-based intervention. PARTICIPANTS: Three hundred twelve community-living people aged 75 and older who had fallen in the previous year. INTERVENTION: Home-based nurse assessment of falls-and-fracture risk factors and home hazards, referral to appropriate community interventions, and strength and balance exercise program. Control group received usual care and social visits. MEASUREMENTS: Primary outcome was rate of falls over 12 months. Secondary outcomes were muscle strength and balance, falls efficacy, activities of daily living, self-reported physical activity level, and quality of life (Medical Outcomes Study 36-item Short Form Questionnaire). RESULTS: Of the 3,434 older adults screened for falls, 312 (9%) from 19 family practices were enrolled and randomized. The average age was 81+/-5, and 69% (215/312) were women. The incidence rate ratio for falls for the intervention group compared with the control group was 0.96 (95% confidence interval=0.70-1.34). There were no significant differences in secondary outcomes between the two groups. CONCLUSION: This nurse-led intervention was not effective in reducing falls in older people who had fallen previously. Implementation and adherence to the fall-prevention measures was dependent on referral to other health professionals working in their usual clinical practice. This may have limited the effectiveness of the interventions.
 
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OBJECTIVE: To determine the effects of environmental tobacco smoke (ETS) exposure on birth outcomes. DESIGN: A systematic review and meta-analysis was performed in accordance with MOOSE guidelines. MEDLINE, EMBASE, CINAHL and LILACS (up to October 2007), were searched and also reviews and reference lists from publications, with no language restrictions. Pooled mean differences and odds ratios (ORs) with 95% confidence intervals were estimated using data extracted from papers, based on random effect models. SETTING: Comparative epidemiological studies. PATIENTS: Pregnant women or women who have given birth. EXPOSURES: Maternal exposure to ETS during pregnancy. MAIN OUTCOME MEASURES: Mean birth weight and proportion of premature infants. RESULTS: 58 studies were included; 53 used cohort designs, 23 ascertaining ETS exposure prospectively and 30 retrospectively; 5 used case-control designs. In prospective studies, ETS exposure was associated with a 33 g (95% CI 16 to 51) reduction in mean birth weight, and in retrospective studies a 40 g (95% CI 26 to 54) reduction. ETS exposure was also associated with an increased risk of low birth weight (birth weight <2500 g; prospective studies: OR 1.32, 95% CI 1.07 to 1.63; retrospective studies: OR 1.22, 95% CI 1.08 to 1.37). The risk of small for gestational age (<10th centile) birth was significantly associated with ETS exposure only in retrospective studies (OR 1.21, 95% CI 1.06 to 1.37). There was no effect of ETS exposure on gestational age. CONCLUSIONS: Exposure of non-smoking pregnant women to ETS reduces mean birth weight by 33 g or more, and increases the risk of birth weight below 2500 g by 22%, but has no clear effect on gestation or the risk of being small for gestational age.
 
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BACKGROUND: Varenicline, a new treatment for smoking cessation, has demonstrated significantly greater efficacy over placebo and sustained release bupropion (bupropion SR). A study was undertaken to compare a 12-week standard regimen of varenicline with a 10-week standard regimen of transdermal nicotine replacement therapy (NRT) for smoking cessation. METHODS: In this 52-week, open-label, randomised, multicentre, phase 3 trial conducted in Belgium, France, The Netherlands, UK and USA, participants were randomly assigned (1:1) to receive varenicline uptitrated to 1 mg twice daily for 12 weeks or transdermal NRT (21 mg/day reducing to 7 mg/day) for 10 weeks. Non-treatment follow-up continued to week 52. The primary outcome was the biochemically confirmed (exhaled carbon monoxide < or = 10 ppm) self-reported continuous abstinence rate (CAR) for the last 4 weeks of the treatment period in participants who had taken at least one dose of treatment. Secondary outcomes included CAR from the last 4 weeks of treatment through weeks 24 and 52, and measures of craving, withdrawal and smoking satisfaction. RESULTS: A total of 376 and 370 participants assigned to varenicline and NRT, respectively, were eligible for analysis. The CAR for the last 4 weeks of treatment was significantly greater for varenicline (55.9%) than NRT (43.2%; OR 1.70, 95% CI 1.26 to 2.28, p<0.001). The week 52 CAR (NRT, weeks 8-52; varenicline, weeks 9-52) was 26.1% for varenicline and 20.3% for NRT (OR 1.40, 95% CI 0.99 to 1.99, p = 0.056). Varenicline significantly reduced craving (p<0.001), withdrawal symptoms (p<0.001) and smoking satisfaction (p<0.001) compared with NRT. The most frequent adverse event was nausea (varenicline, 37.2%; NRT, 9.7%). CONCLUSIONS: The outcomes of this trial established that abstinence from smoking was greater and craving, withdrawal symptoms and smoking satisfaction were less at the end of treatment with varenicline than with transdermal NRT. TRIAL REGISTRATION NUMBER: NCT00143325.
 
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BACKGROUND: Prevention of type 2 diabetes in adults is a far better option than treatment, to alleviate pressure on health care providers and resources. However, there is no current review of the evidence regarding the efficacy of a diet-only intervention for prevention. OBJECTIVES: To assess the effects of type and frequency of dietary advice for the prevention of type 2 diabetes mellitus. SEARCH STRATEGY: We carried out a comprehensive search of The Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED, bibliographies and contacted relevant experts. SELECTION CRITERIA: All randomised controlled trials, of twelve months or longer, in which dietary advice for the prevention of type 2 diabetes was the only intervention in adults. DATA COLLECTION AND ANALYSIS: The lead investigator performed all data extraction and quality scoring with duplication being carried out by one of the other four investigators independently with discrepancies resolved by discussion and consensus. Authors were contacted for missing data. Change data are presented. MAIN RESULTS: Two trials which randomised 358 people to dietary treatment and control groups were identified. Longest duration of follow-up was six years.In the 6-year Da Qing IGT & Diabetes study, the incidence of type 2 diabetes in the control group was 67.7% (95% confidence interval (CI) 59.8% to 75.2%) which was reduced to 43.8% (95% CI 35.5% to 54.7%) in the diet group. Overall, the dietary intervention group had a 33% reduction in the incidence of diabetes after six years (P < 0.03). The Oslo Diet & Exercise Study (ODES) found significant (P<0.05) reductions in insulin resistance, fasting insulin (pmol/L), fasting C-peptide (pmol/L), fasting proinsulin (pmol/L), fasting blood glucose (mmol/L), BMI (kg/m(2)), mBP (mmHg) and fasting triglycerides (mmol/L), and a significant increase in fasting HDL cholesterol (mmol/L) and PAI-1 (U/ml) after 12 months of dietary intervention.Data on mortality, morbidity, health-related quality of life, adverse effects, costs were not reported in either study. AUTHORS` CONCLUSIONS: There are no high quality data on the efficacy of dietary intervention for the prevention of type 2 diabetes. More well-designed, long-term studies, providing well-reported, high-quality data are required before proper conclusions can be made into the best dietary advice for the prevention of diabetes mellitus in adults.
 
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Epidemiological studies first demonstrated the association between obesity and asthma and they have begun to provide additional evidence to support causality: a dose-effect relationship, consistency across studies (especially among women) and the correct temporal order (ie, obesity before asthma). To date, relatively few studies have addressed reversibility, an important but less frequently demonstrated epidemiological criterion of causality. Reversibility suggests that if excessive weight is a risk factor for asthma, then reducing body weight should decrease the prevalence of asthma, or at least decrease asthma related symptoms or health care utilisation. We performed a systematic review on weight loss and asthma, based on searches between January 1966 and January 2007 of both PubMed and the Cochrane Clinical Trial Database. Of the 15 relevant studies, asthma was the primary outcome in only five. Only one study was conducted in children. Regardless of the type of intervention (surgical vs medical), all 15 studies noted an improvement in at least one asthma outcome after weight loss. The improvement was noted across studies that differed in sample age, gender or country of origin. The heterogeneity of the interventions and outcomes precluded quantitative synthesis. We briefly review the role of specific factors (eg, gastro-oesophageal reflux) in the weight loss-asthma association, and potential directions for future research.
 
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