The aim of this review is to analyze the available literature regarding the neuropsychiatric (NP) disturbances associated with corticosteroid (CS) therapy; to determine the nature, severity, and frequency of these NP symptoms; and to identify the various risk factors involved in the development of CS-induced NP disturbances. We searched the available literature since the advent of corticosteroid therapy (1950) utilizing the PubMed database ( www.pubmed.gov). Primary articles were identified, and they and their pertinent references were reviewed. Due to potential confusion between NP manifestations of CS therapy and central nervous system (CNS) involvement of systemic lupus erythematosus (SLE), a condition often treated with CS, a brief review of NP manifestations of SLE was also performed. The presentation of CS-induced neuropsychiatric disorders (CIPD) can be quite varied with depression, hypomania, and overt psychosis being the most common manifestations. CIPD can also include bipolar affective changes, delirium, panic attacks, agoraphobia, obsessive-compulsive disorder, anxiety, insomnia, restlessness, fatigue, catatonia, reversible dementia-like cognitive changes, impaired memory, and concentration. No factors have been identified that allow for the accurate prediction of development of CIPD. A dose-dependent relationship (increased risk when the daily prednisone-equivalent dose is ≥40 mg) has been observed in most cases of CIPD, although there have been case reports with lower doses, alternate-day therapy, and even inhaled CS. Women are more commonly affected with most symptoms occurring in the first 6 weeks of starting treatment. SLE has been the only specific illness that has been linked to a greater risk of CIPD and the NP manifestations of SLE may mimic those of CIPD, with most occurring in the first year of diagnosis. Antiribosomal P, antineuronal, or antiphospholipid antibodies are frequently seen in patients with SLE developing CIPD. Imaging and EEG abnormalities, the coexistence of non-CNS manifestations of SLE, and the presence of serious disturbances in memory and concentration are more suggestive of NP-SLE than CIPD. Although NP symptoms associated with the use of CS generally resolve with discontinuation of the medication, prophylaxis with lithium, and treatment with antidepressants, anticonvulsants and electroconvulsive therapy for severe mania and depression have been reported with successful outcomes. A greater understanding of the underlying mechanism of CIPD, risk factors involved, treatment options, and the distinguishing features from NP-SLE will ultimately lead to more directed therapy for such patients.
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et al. Physical exercise during pregnancy and the risk of preterm birth: a study within the Danish National Birth Cohort. Am J Epidemiol. 2008;167: 859-866. Objective: To examine the relation between physical exercise during pregnancy and the risk of preterm birth in a large cohort of women. Design: Prospective, observational, cohort study. Setting: Nationwide study with recruitment through general practitioners, during the period 1996 to 2002. Participants: Pregnant women were recruited into the Danish National Birth Cohort. Approximately 50% of Danish general practitioners collaborated, and 60% of the invited women agreed to participate. After exclusions (pregnancy terminated before 22 weeks of gestation; or interview took place after 37 weeks of gestation) 89 196 women completed the first computer-assisted telephone interview at a median gestational age of 16.3 completed weeks, and 82 965 women (93%) completed a second interview at a median gestational age of 31.1 completed weeks. Assessment of risk factors: Both interviews included questions on the respondents' physical exercise during the current pregnancy. Type, duration, and frequency of exercise were recorded for each activity. Physical exercise was summarized into 6 categories of hours per week, from 0 h/wk to .5 h/wk. The type of preferred exercise was categorized as swimming, low impact activities, high impact activities, fitness training, bicycle riding, horseback riding, and miscellaneous. Changes in physical activity from interview 1 to interview 2 were noted. Potential confounders such as variables within the pregnancy, the health and reproductive history of the mother, and her lifestyle, social, and work factors were assessed. Main outcome measures: The main outcome measure was the relation of preterm birth to the mother's physical activity. Gestational age of the birth was obtained from birth record data reported to the National Patient Registry in Denmark. Preterm birth was defined as delivery (live or stillbirth) after 22 weeks and before 36 completed weeks of gestation. Preterm births were subcategorized as 22-27, 28-31, and 32-36 completed weeks of gestation.Main results: Most of the women (63%) did not do any kind of physical exercise at the time of the first interview. The proportion increased to 70% at the second interview. Among the active women, swimming, low-impact activities and bicycling were the preferred activities at both interviews. Exercising .2 h/wk was uncommon, and in late pregnancy approximately half the active women exercised for #1 h/wk. The number of preterm births was 4279 (4.9% of singleton pregnancies). Hazard ratios (HR) for preterm birth were lower for women who did any exercise compared with those who did none (unadjusted HR, 0.86 and adjusted HR, 0.82; 95% CI, 0.76-0.88). Although HR for preterm birth were significantly lower for women who exercised .0 to #1 h/wk and .1 to #2 h/wk than for the nonexercisers, there was no trend for an association between fewer preterm births and increasing exercise when the no-exe...
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