Role of diet and NSAIDs in the chemoprevention of colorectal cancer.

Colorectal cancer is a major public health problem. It is also one of the most preventable cancers. Although the colorectal cancer incidence and mortality in whites have been declining over the past 2 decades, these statistics are rising in nearly all ethnic minority groups. The development of colorectal cancer is influenced by exogenous factors, such as dietary constituents and drugs. While reputable data on the chemopreventive effects of diet and drugs, such as nonsteroidal anti-inflammatory drugs (NSAIDs), in specific minority groups are limited, evidence suggests that dietary factors may affect colorectal carcinogenesis in various ethnic minority groups. Clearly, more studies are necessary to resolve these questions. Because the risk of colorectal cancer is increasing in minority patients, they cannot wait for the results of such studies. Therefore, until definitive data are available, it is prudent for physicians to recommend that all individuals be screened for colorectal cancer according to accepted guidelines and to educate them regarding healthful eating habits that will prevent the development of colorectal cancer. Physicians should be particularly vigilant in recommending these approaches to minority patients. Patients should be advised to consume a well-balanced, low-fat, high-fiber diet that is rich in fruits and vegetables.

Cortisol metabolism in hypertensive patients who do and do not develop hypokalemia from diuretics.

Deficiency of 11 beta-hydroxysteroid dehydrogenase causes hypertension and hypokalemia. To test whether hypertensive patients who develop hypokalemia when treated with diuretics have low levels of activity of this enzyme as a metabolic predisposition to the development of hypokalemia, we measured urinary cortisone, cortisol, tetrahydrocortisol, tetrahydrocortisone, and creatinine in 42 hypertensive patients who either did or did not become hypokalemic on hydrochlorothiazide. The mean ratios of cortisone to cortisol, tetrahydrocortisone to tetrahydrocortisol, tetrahydrocortisol to cortisol, and cortisol to creatinine did not differ between the two groups. We conclude that hypertensives who develop hypokalemia on diuretics do not have low activity of this enzyme. They also do not appear to have low ring A reduction or higher cortisol secretion rates compared with hypertensives who do not develop hypokalemia. We failed to find a metabolic predisposition to the development of hypokalemia by diuretic treatment.

Impact of advanced maternal age on the outcome of pregnancy.

We assessed the impact of advanced maternal age on the outcome of pregnancy by studying all 1,328 women who were primarily cared for and delivered at our institution between 14 September 1984 and 12 February 1985. Important peripartum maternal complications were no more frequent in women aged 35 years or more than in women 20 to 34 years old, although operative delivery was significantly more common. Similarly, adverse outcomes of infants were no more frequent. Perinatal mortality tended to be lower. In addition, we noted a trend for fewer infants with congenital anomalies to be born among older women. This trend was related, in part, to the choice to terminate the pregnancy by women with fetuses that had documented chromosomal anomalies. We conclude that advanced maternal age was not associated with an excess of adverse pregnancy outcome and suggest that, with early registration and careful surveillance during pregnancy, women aged 35 years or more can experience excellent pregnancy outcomes.

PIP: The obstetric outcome of 1328 deliveries in a tertiary level hospital was examined, focusing on the results of the women over 35. The study group were all pregnant women over 20 primarily cared for and delivered at the New York Hospital-Cornell Medical Center from September 1984- February 1985, excluding those transferred from other institutions for complications. Among the older women, there was a higher incidence of previous abdominal operations, cesarean sections, previous perinatal death, infertility and alcohol abuse, but relatively few had comorbid conditions or obesity. Most were of higher socioeconomic status and had private physicians. The older group tended to begin prenatal care early, and elect to have amniocentesis. They had a higher risk of gestational glucose intolerance, hypertension and hospitalization during this pregnancy. 45% had cesarean delivery, and their hospital stays were longer. Their rates of vertex presentation, prematurity, postmaturity, macrosomia, induced or augmented labor were similar to those of younger women. There were no maternal deaths. The older group had 1 multiple birth, fewer than the younger women. Perinatal mortality was lowest in the older women. There was 1 intrauterine death and 1 congenital anomaly, lower rates than seen in younger women. This series demonstrates that women over 35 are not at greater risk of adverse pregnancy outcomes if they are cared for early and carefully.

The impact of universal screening for gestational glucose intolerance on outcome of pregnancy.

Universal screening for gestational glucose intolerance has strong support, despite the lack of scientific evidence documenting its benefit. In the early 1980s, practicing obstetricians were split concerning the clinical importance of gestational glucose intolerance, so that some practitioners tested virtually all the patients they treated while others tested none. This historical reality provided concurrent screened and unscreened populations in whom to assess the impact of screening. We studied all 1,307 singleton pregnancies cared for and delivered at the New York Hospital-Cornell University Medical Center during a five month period. Large infants (birth weight greater than or equal to 4,000 grams) were born to 10.5 per cent of the women who were not screened (533) and to 11.2 per cent of the women who were screened (774). The process of screening not only failed to decrease the rate of large infants, but also failed to improve otherwise pregnancy outcomes and was associated with more intensive surveillance during pregnancy and a significantly higher rate of primary cesarean delivery. Given the unexpected concomitants of the screening process, we conclude that recommendations for universal screening for gestational glucose intolerance should be reconsidered.

Should all pregnant women be screened for gestational glucose intolerance?

Although gestational glucose intolerance is associated with the remote development of diabetes mellitus, the risk to the mother during the index pregnancy and the risk to her fetus remain uncertain. Nevertheless, universal screening for gestational glucose intolerance has many strong advocates. The scientific data supporting a universal screening programme--showing that treatment of gestational glucose intolerance does more good than harm--are limited. Until the evidence can be extended beyond that on infant birthweight, a more restrained approach than universal screening may be appropriate.