Marijuana Use During Pregnancy

(Canada—Canadian Family Physician, February 2001, p. 263.) Marijuana contains more than 400 chemicals and the relative proportion of the various pharmacologically active ingredients varies. Studies on the effects prenatal maternal marijuana use has on the developing child are complicated by the large number of confounding variables, such as the use of tobacco, alcohol and other drugs. Several studies have demonstrated a small reduction in birth weight with heavy maternal use of marijuana. No specific malformation has been linked with even heavy use. Although maternal use of marijuana has been suspected as a risk factor for some rare childhood cancers such as rhabdomyosarcoma, the data for this and for any effect on overall infant mortality are inconclusive. Evidence associates maternal marijuana use during pregnancy with sleep disturbances, hyperactivity inattention, poorer visual problem-solving skills and delinquency in children. Overall, data are inconclusive about the adverse effects of marijuana use during pregnancy on the developing child. However, the American Academy of Pediatrics recommends against marijuana use during pregnancy and lactation.

Cervical Disc Prolapse

(Great Britain—The Practitioner, December 2000, p. 1034.) Prolapse of a disc in the cervical spine is about 20 times less common than prolapse in the lumbar area. Cervical disc prolapse may occur as a result of “wear and tear,” osteophyte formation or acute injury. Patients usually present with pain in the neck, shoulder and/or arms. Although the pain may be sharp, it is usually deep and gnawing, depending on the pathology and nerve roots involved. Sensory disturbances, such as numbness or tingling occurring in a dermatomal pattern in the upper limbs, can be more useful than pain in establishing the diagnosis of cervical disc prolapse. Muscle weakness follows a myotomal pattern determined by the level of the nerve root compression. Restricted movement, muscle wasting, sensory changes and absence of deep tendon reflexes may be apparent on examination. Patients with arm pain secondary to cervical disc prolapse usually respond well to analgesia, lifting restrictions and use of a soft cervical collar. Physical therapy and muscle relaxants have not been shown to benefit patients. Neck manipulation is not recommended because it is potentially hazardous. Prompt surgical referral is indicated in patients with evidence of cord compression and should also be considered in patients with significant or prolonged pain or weakness refractory to medical therapy.

Changing to Insulin Use in Type 2 Diabetes

(Great Britain—The Practitioner, November 2000, p. 986.) The initial management of type 2 diabetes is based on diet and oral hypoglycemic medications, but up to one half of patients require insulin therapy within 10 years of diagnosis. Increasing insulin resistance and progressive beta cell failure can be monitored by glycosylated hemoglobin A_1c levels. If these levels are consistently more than 130 percent of the upper limit of the reference range, use of insulin should be seriously considered, regardless of symptoms. The transition to insulin should be seen as a positive move to reduce complications, although both patient and physician may be concerned about “failure” of oral medication and the complexity of insulin injections and monitoring. Because many patients gain weight when insulin is introduced, they should reduce their caloric intake and increase their exercise. Many patients do well with a twice-daily program of intermediate-acting insulin mixed with short-acting insulin but require substantial support during the transition from oral medication.

Peripheral Corneal Thinning in RA

(Canada—Canadian Family Physician, September 2000, p. 1757.) Many collagen vascular diseases, particularly rheumatoid arthritis (RA), can result in thinning of the peripheral cornea. The pathology appears to involve obliterative microangiitis, and the degree of keratolysis is proportional to the degree of vascular occlusion. Patients may be asymptomatic or may experience mild eye pain and photophobia. Peripheral corneal thinning eventually leads to corneal ulceration. Treatment of corneal thinning includes erythromycin ointment and nocturnal patching plus the use of artificial tears every one to two hours in the daytime to ensure adequate lubrication. If corneal thinning is severe, treatment with oral prednisone plus an antiulcer agent such as ranitidine may be effective. Immunosuppressive agents and surgery have also been used. Pain and photophobia are usually treated with cycloplegic drops, such as atropine. If the condition progresses despite maximal medical therapy, surgery is warranted.