PRETERM BIRTH AND FETAL GROWTH RESTRICTION IN HIV-INFECTED BRAZILIAN PREGNANT WOMEN

Introduction:

Maternal HIV infection and related co-morbidities may have two outstanding consequences to fetal health: mother-to-child transmission (MTCT) and adverse perinatal outcomes. After Brazilian success in reducing MTCT, the attention must now be diverted to the potentially increased risk for preterm birth (PTB) and intrauterine fetal growth restriction (IUGR).

Objective:

To determine the prevalence of PTB and IUGR in low income, antiretroviral users, publicly assisted, HIV-infected women and to verify its relation to the HIV infection stage.

Patients and Methods:

Out of 250 deliveries from HIV-infected mothers that delivered at a tertiary public university hospital in the city of Vitória, state of Espírito Santo, Southeastern Brazil, from November 2001 to May 2012, 74 single pregnancies were selected for study, with ultrasound validated gestational age (GA) and data on birth dimensions: fetal weight (FW), birth length (BL), head and abdominal circumferences (HC, AC). The data were extracted from clinical and pathological records, and the outcomes summarized as proportions of preterm birth (PTB, < 37 weeks), low birth weight (LBW, < 2500g) and small (SGA), adequate (AGA) and large (LGA) for GA, defined as having a value below, between or beyond the ±1.28 z/GA score, the usual clinical cut-off to demarcate the 10th and 90th percentiles.

Results:

PTB was observed in 17.5%, LBW in 20.2% and SGA FW, BL, HC and AC in 16.2%, 19.1%, 13.8%, and 17.4% respectively. The proportions in HIV-only and AIDS cases were: PTB: 5.9 versus 27.5%, LBW: 14.7% versus 25.0%, SGA BW: 17.6% versus 15.0%, BL: 6.0% versus 30.0%, HC: 9.0% versus 17.9%, and AC: 13.3% versus 21.2%; only SGA BL attained a significant difference. Out of 15 cases of LBW, eight (53.3%) were preterm only, four (26.7%) were SGA only, and three (20.0%) were both PTB and SGA cases. A concomitant presence of, at least, two SGA dimensions in the same fetus was frequent.

Conclusions:

The proportions of preterm birth and low birth weight were higher than the local and Brazilian prevalence and a trend was observed for higher proportions of SGA fetal dimensions than the expected population distribution in this small casuistry of newborn from the HIV-infected, low income, antiretroviral users, and publicly assisted pregnant women. A trend for higher prevalence of PTB, LBW and SGA fetal dimensions was also observed in infants born to mothers with AIDS compared to HIV-infected mothers without AIDS.     

The prognostic value of a normal oral glucose tolerance test in pregnant women who tested positive at screening: a validation study

Background

Controversies surround a diagnosis of gestational diabetes mellitus (GDM). The objective of this study was to evaluate the oral glucose tolerance test (OGTT) for the prediction of adverse gestational and perinatal outcomes in pregnant women with a positive screening test for diabetes mellitus and a negative diagnosis, i.e. a normal 3-hour OGTT.

Methods

This validation study evaluated 409 pregnant women who tested positive for diabetes mellitus at screening. Perinatal and maternal outcomes were considered. Sensitivity and specificity were calculated for each of the values of the OGTT as a diagnostic test, with the gold standard being perinatal outcome.

Results

The most frequent risk factors were obesity, arterial hypertension and advanced maternal age. The most common neonatal outcomes were large-for-gestational-age infants, Cesarean delivery and preterm birth. A fasting blood glucose level of 87 mg/dL was the most powerful predictor of adverse perinatal outcome.

Conclusions

At the cut-off level adopted by the American Diabetes Association, gestational OGTT was able to successfully identify in which pregnant women outcome would be unfavorable.     

Associations of Prenatal and Perinatal Factors with Cortisol Diurnal Pattern and Reactivity to Stress at Preschool Age Among Children Living in Poverty

Objective:

To examine the association of pre- and perinatal factors with diurnal cortisol pattern and reactivity to a stressor at preschool age among children living in poverty.

Methods:

Preschool aged children (n=275) provided saliva samples 3 times per day for 3 days to assess circadian rhythmicity (intercept and slope reflected diurnal pattern) and during a behavioral stress elicitation protocol to measure reactivity (5 samples before, during and after the stressor). Pre- and perinatal predictors were pregnancy weight gain, pre-pregnancy body mass index (BMI), infant birth weight z-score and gestational age. We ran 7 linear regression models predicting each of the cortisol outcomes including all pre- and perinatal predictors and covariates simultaneously.

Results:

Greater pregnancy weight gain predicted higher morning cortisol [b=0.020 (SE 0.007), p=0.003]. Greater pregnancy weight gain also predicted higher cortisol at recovery from the stressor in girls only [β=0.002 (SE 0.001), p=0.036]. There was no association of pre-pregnancy BMI with any cortisol outcome. Higher birth weight z-score predicted higher morning cortisol in the total sample [β=0.134 (SE 0.066, p=0.043]. Greater gestational age predicted lower cortisol during peak stress in the sample who underwent cortisol reactivity testing [β=-0.015 (SE 0.007), p=0.032] and in boys [β=-0.032 (SE 0.014), p=0.027].

Conclusion:

Pre- and perinatal factors are associated with cortisol patterning in offspring at preschool age. The implications for child health require additional studies.     

Airway pressure release ventilation: A neonatal case series and review of current pediatric practice

BACKGROUND:

The use of airway pressure release ventilation (APRV) in very low birth weight infants is limited.

OBJECTIVE:

To report the authors’ institutional experience and to review the current literature regarding the use of APRV in pediatric populations.

METHODS:

Neonates <1500 g ventilated using APRV from 2005 to 2006 at McMaster Children’s Hospital (Hamilton, Ontario) were retrospectively reviewed. Publications describing APRV in children from 1987 to 2011 were reviewed.

RESULTS:

Five infants, 24 to 28 weeks’ gestational age, were ventilated using APRV. Indications for APRV were refractory hypoxemia (n=3), ventilatory dyssynchrony (n=1) and minimizing sedatives (n=1). All infants appeared to tolerate APRV well with no recorded adverse events. Current pediatric evidence regarding APRV is primarily observational. Published experience reveals that APRV settings in pediatrics often approximate those used in adults, thus deviating from the original guidelines recommended in children. Clinical outcomes, such as oxygenation, ventilation and sedation requirements, are inconsistent.

CONCLUSIONS:

APRV is primarily used as a rescue ventilation mode in children. Neonatal evidence is limited; however, the present study indicates that APRV is feasible in very low birth weight infants. There are unique considerations when applying this mode in small infants. Further research is necessary to confirm whether APRV is a safe and effective ventilation strategy in this population.     

Maternal Factors and Adverse Perinatal Outcomes in Women with Preeclampsia in Maceió, Alagoas

Background

Preeclampsia has been associated with several risk factors and events. However, it still deserves further investigation, considering the multitude of related factors that affect different populations.

Objective

To evaluate the maternal factors and adverse perinatal outcomes in a cohort of pregnant women with preeclampsia receiving care in the public health network of the city of Maceió.

Methods

Prospective cohort study carried out in 2014 in the public health network of the city with a sample of pregnant women calculated based on a prevalence of preeclampsia of 17%, confidence level of 90%, power of 80%, and ratio of 1:1. We applied a questionnaire to collect socioeconomic, personal, and anthropometric data, and retrieved perinatal variables from medical records and certificates of live birth. The analysis was performed with Poisson regression and chi-square test considering p values < 0.05 as significant.

Results

We evaluated 90 pregnant women with preeclampsia (PWP) and 90 pregnant women without preeclampsia (PWoP). A previous history of preeclampsia (prevalence ratio [PR] = 1.57, 95% confidence interval [95% CI] 1.47 - 1.67, p = 0.000) and black skin color (PR = 1.15, 95% CI 1.00 - 1.33, p = 0.040) were associated with the occurrence of preeclampsia. Among the newborns of PWP and PWoP, respectively, 12.5% and 13.1% (p = 0.907) were small for gestational age and 25.0% and 23.2% (p = 0.994) were large for gestational age. There was a predominance of cesarean delivery.

Conclusion

Personal history of preeclampsia and black skin color were associated with the occurrence of preeclampsia. There was a high frequency of birth weight deviations and cesarean deliveries.     

On the Problem of Patient-Specific Endogenous Glucose Production in Neonates on Stochastic Targeted Glycemic Control

Background:

Both stress and prematurity can induce hyperglycemia in the neonatal intensive care unit, which, in turn, is associated with worsened outcomes. Endogenous glucose production (EGP) is the formation of glucose by the body from substrates and contributes to blood glucose (BG) levels. Due to the inherent fragility of the extremely low birth weight (ELBW) neonates, true fasting EGP cannot be explicitly determined, introducing uncertainty into glycemic models that rely on quantifying glucose sources. Stochastic targeting, or STAR, is one such glycemic control framework.

Methods:

A literature review was carried out to gather metabolic and EGP values on preterm infants with a gestational age (GA) <32 weeks and a birth weight (BW) <2 kg. The data were analyzed for EGP trends with BW, GA, BG, plasma insulin, and glucose infusion (GI) rates. Trends were modeled and compared with a literature-derived range of population constant EGP models using clinically validated virtual trials on retrospective clinical data.

Results:

No clear relationship was found for EGP and BW, GA, or plasma insulin. Some evidence of suppression of EGP with increasing GI or BG was seen. Virtual trial results showed that population-constant EGP models fit clinical data best and gave tighter control performance to a target band in virtual trials.

Conclusions:

Variation in EGP cannot easily be quantified, and EGP is sufficiently modeled as a population constant in the neonatal intensive care insulin–nutrition–glucose model. Analysis of the clinical data and fitting error suggests that ELBW hyperglycemic preterm neonates have unsuppressed EGP in the higher range than that seen in literature.     

Recognition and Reporting of AKI in Very Low Birth Weight Infants

Background and objectives

AKI is associated with both increased short-term morbidity and mortality and greater long-term risk for CKD. This study determined the prevalence of AKI among very low birth weight infants using a modern study definition, evaluated the frequency of AKI diagnosis reporting in the discharge summary, and determined whether infants were referred to a pediatric nephrologist for AKI follow-up.

Design, setting, participants, & measurements

Records of very low birth weight infants admitted to a level IV neonatal intensive care unit from 2008 to 2011 were reviewed. AKI was classified using the Kidney Disease: Improving Global Outcomes definition modified to include only serum creatinine.

Results

AKI occurred in 39.8% of 455 infants; 75 (16.5%) infants experienced multiple episodes of AKI, and 8 (2%) infants were discharged with an abnormal last creatinine. Updated clinical risk index for babies score >10 (odds ratio, 12.9; 95% confidence interval, 7.8 to 21.4) and gestational age <28 weeks (odds ratio, 10.6; 95% confidence interval, 6.8 to 16.7) were strongly associated with AKI in univariate analyses. AKI was associated with increased mortality (odds ratio, 4.0; 95% confidence interval, 1.4 to 11.5) and length of stay (11.7 hospital days; 95% confidence interval, 5.1 to 18.4), even after accounting for gestational age, birth weight, and updated clinical risk index for babies score. AKI was recorded in the discharge summary for only 13.5% of AKI survivors. No infants were referred to a nephrologist for AKI follow-up.

Conclusions

AKI occurred in 40% of very low birth weight infants and was concentrated in the most premature and severely ill infants. One in six infants experienced multiple episodes of AKI, and a small number of infants was discharged with an elevated serum creatinine. Reporting a history of AKI in the discharge summary occurred infrequently, and referral to a nephrologist for AKI follow-up did not occur, highlighting areas for quality improvement.     

Statins and New-Onset Diabetes Mellitus and Diabetic Complications: A Retrospective Cohort Study of US Healthy Adults

Background

Statin use is associated with increased incidence of diabetes and possibly with increased body weight and reduced exercise capacity. Data on the long-term effects of these associations in healthy adults, however, are very limited. In addition, the relationship between these effects and diabetic complications has not been adequately studied.

Objective

To examine the association between statin use and new-onset diabetes, diabetic complications, and overweight/obesity in a cohort of healthy adults.

Research Design

This was a retrospective cohort study.

Participants

Subjects were Tricare beneficiaries who were evaluated between October 1, 2003 and March 1, 2012. Patients were divided into statin users and nonusers.

Intervention

We excluded patients who, at baseline, had a preexisting disease indicative of cardiovascular diseases, any positive element of the Charlson comorbidity index (including diabetes mellitus), or life-limiting chronic diseases. Using 42 baseline characteristics, we generated a propensity score to match statin users and nonusers.

Main Measures

Outcomes assessed included new-onset diabetes, diabetic complications, and overweight/obesity.

Key Results

A total of 25,970 patients (3982 statin users and 21,988 nonusers) were identified as healthy adults at baseline. Of these, 3351 statins users and 3351 nonusers were propensity score-matched. Statin users had higher odds of new-onset diabetes (odds ratio [OR] 1.87; 95 % confidence interval [95 % CI] 1.67–2.01), diabetes with complications (OR 2.50; 95 % CI 1.88–3.32), and overweight/obesity (OR 1.14; 95 % CI 1.04–1.25). Secondary and sensitivity analyses demonstrated similar findings.

Conclusions

Diabetes, diabetic complications, and overweight/obesity were more commonly diagnosed among statin-users than similar nonusers in a healthy cohort of adults. This study demonstrates that short-term clinical trials might not fully describe the risk/benefit of long-term statin use for primary prevention.KEY WORDS: Overweight/obesity, Diabetes, Diabetic complications, Adverse events, Observational study, Satins, Primary prevention     

Reference values for resistance and compliance based on the single occlusion technique in healthy infants from Southeast China

Background

Respiratory disease is a major cause of morbidity and mortality in infants and has a large impact on health care. The aim of this study was to present the reference values of resistance and compliance by using a single occlusion technique (SOT) in healthy infants in Southeast China.

Methods

Respiratory compliance (Crs) and respiratory resistance (Rrs) were measured in healthy infants, aged 1–96 weeks, by using SOT in the Children’s Hospital of FuDan University (Shanghai, China). For comparison, the infants were grouped by age as follows: 1–24, 25–48, 49–72 and 73–96 weeks. Multiple regression analysis was performed using age, length, weight, and body mass index (BMI) as the independent variables to obtain predictive equations, separated according to sex.

Results

We measured 205 healthy infants from birth up to 96 weeks of age (112 boys, 93 girls). Height and weight increased significantly with age. The Rrs declined with length, whereas the Crs increased. The median Rrs was 5.04 kPa/L/sec (range, 3.73–6.82 kPa/L/sec), and the mean Crs was 119.52±60.47 mL/kPa. Regression equations for Rrs and Crs were obtained.

Conclusions

We obtained reference values for passive respiratory mechanics by using SOT in healthy infants from Southeast China. These data provide references for assessing the normality of SOT measurements in infants.     

A Systematic Review and Meta-Analysis of Outcomes of Pregnancy in CKD and CKD Outcomes in Pregnancy

Background and objectives

We undertook a systematic review and meta-analysis of published cohort studies and case-control studies to estimate (1) the risk of pregnancy complications among patients with CKD versus those without CKD and (2) the risk of CKD progression among pregnant patients versus nonpregnant controls with CKD.

Design, setting, participants, & measurements

We searched electronic databases for studies published between 1946 and 2014, and we reviewed articles using validity criteria. Random-effects analytical methods were used.

Results

Twenty-three studies (14 with data for adverse pregnancy outcomes and 9 for renal outcomes) with 506,340 pregnancies were included. Pregnancy with CKD had greater odds of preeclampsia (odds ratio [OR], 10.36; 95% confidence interval [95% CI], 6.28 to 17.09), premature delivery (OR, 5.72; 95% CI, 3.26 to 10.03), small for gestational age/low birth weight (OR, 4.85; 95% CI, 3.03 to 7.76), cesarean section (OR, 2.67; 95% CI, 2.01 to 3.54), and failure of pregnancy (OR, 1.80; 95% CI, 1.03 to 3.13). Subgroup analysis showed that odds of preeclampsia (P<0.01) and premature delivery (P<0.01) were higher in women with nondiabetic nephropathy compared with diabetic nephropathy, and the odds of preeclampsia (P=0.01) and premature delivery (P<0.01) were higher in women with macroproteinuria compared with microproteinuria. The median for follow-up time for renal events was 5 years (interquartile range, 5–14.7 years). There were no significant differences in the occurrence of renal events between CKD pregnant women and those without pregnancy (OR, 0.96; 95% CI, 0.69 to 1.35). Subgroup analysis showed that publication year, sample size, follow-up years, type of primary disease, CKD classification, level of serum creatinine at baseline, proteinuria, and level of systolic BP did not modify the renal outcomes.

Conclusions

The risks of adverse maternal and fetal outcomes in pregnancy are higher for women with CKD versus pregnant women without CKD. However, pregnancy was not a risk factor for progression of renal disease in women with CKD before pregnancy.     

Metabolic Syndrome and Importance of Associated Variables in Children and Adolescents in Guabiruba - SC,Brazil

Background

The risk factors that characterize metabolic syndrome (MetS) may be present in childhood and adolescence, increasing the risk of cardiovascular disease in adulthood.

Objective

Evaluate the prevalence of MetS and the importance of its associated variables, including insulin resistance (IR), in children and adolescents in the city of Guabiruba-SC, Brazil.

Methods

Cross-sectional study with 1011 students (6-14 years, 52.4% girls, 58.5% children). Blood samples were collected for measurement of biochemical parameters by routine laboratory methods. IR was estimated by the HOMA-IR index, and weight, height, waist circumference and blood pressure were determined. Multivariate logistic regression models were used to examine the associations between risk variables and MetS.

Results

The prevalence of MetS, IR, overweight and obesity in the cohort were 14%, 8.5%, 21% and 13%, respectively. Among students with MetS, 27% had IR, 33% were overweight, 45.5% were obese and 22% were eutrophic. IR was more common in overweight (48%) and obese (41%) students when compared with eutrophic individuals (11%; p = 0.034). The variables with greatest influence on the development of MetS were obesity (OR = 32.7), overweight (OR = 6.1), IR (OR = 4.4; p ≤ 0.0001 for all) and age (OR = 1.15; p = 0.014).

Conclusion

There was a high prevalence of MetS in children and adolescents evaluated in this study. Students who were obese, overweight or insulin resistant had higher chances of developing the syndrome.     

Role of age at asthma diagnosis in the asthma-obesity relationship

OBJECTIVE:

To determine whether age at asthma diagnosis has an impact on the previously described relationship between asthma and obesity.

METHODS:

Data were provided from Cycle 1.1 (2000/2001) of the Canadian Community Health Survey, a nationally representative health survey that included 6871 participants (2464 males and 4407 females) with asthma. Body mass index was used to categorize participants as normal weight (18.5 kg/m² to 24.9 kg/m²), overweight (25 kg/m² to 29.9 kg/m²) or obese (30 kg/m² or greater). Multivariate logistic regression analyses were used to estimate the odds of overweight and obesity by self-reported age at asthma diagnosis, after accounting for current age and other covariables.

RESULTS:

In fully adjusted models, males diagnosed with asthma during adolescence (12 to 20 years of age) were at elevated odds of obesity (OR 1.58; 95% CI 1.03 to 2.43) compared with asthmatic patients diagnosed during childhood (0 to 11 years of age). Women diagnosed with asthma in mid life (21 to 44 years of age) and later life (45 to 64 years of age) were 43% (OR 1.43; 95% CI 1.08 to 1.90) and 56% (OR 1.56; 95% CI 1.00 to 2.44) more likely to be obese than those diagnosed in childhood, respectively.

CONCLUSIONS:

The impact of age at asthma diagnosis on the asthma-obesity relationship differed between males and females. However, the identification of high-risk groups of asthmatic patients may strengthen primary prevention strategies for obesity and related comorbidities at multiple levels of influence.     

Sleep duration and weight loss among overweight/obese women enrolled in a behavioral weight loss program

Objective:

The purpose of this study was to examine whether baseline sleep duration predicts weight loss outcomes in a randomized controlled trial examining a behavioral weight loss (BWL) intervention among overweight and obese (OW/OB) women with urinary incontinence; and whether participation in the BWL intervention is associated with changes in sleep duration.

Design:

Longitudinal, clinical intervention study of a 6-month BWL program.

Subjects:

Three hundred sixteen OW/OB women, with urinary incontinence (age: 30–81 years, body mass index (BMI; 25–50 kg m⁻²) enrolled from July 2004–April 2006.

Measurements:

Measured height and weight, self-report measures of demographics, sleep and physical activity.

Results:

Neither self-reported total sleep time (TST) nor time in bed (TIB) at baseline significantly predicted weight loss outcomes among OW/OB women in a BWL treatment. BWL treatment was successful regardless of how much subjects reported sleeping at baseline, with an average weight loss of 8.19 kg for OW/OB women receiving BWL treatment, versus a weight loss of 1.44 kg in the control condition. Similarly, changes in weight, BMI and incontinence episodes did not significantly predict changes in sleep duration or TIB across the treatment period.

Conclusion:

Although epidemiological and cross-sectional studies support a relationship between short sleep and increased BMI, the present study found no significant relationship between TST or TIB and weight loss for OW/OB women participating in a BWL treatment.     

Pregnancy outcomes in women with chronic kidney disease: a systematic review

Summary

Background and objectives

Pregnant women with chronic kidney disease (CKD) are at risk of adverse maternal and fetal outcomes. We conducted a systematic review of observational studies that described this risk.

Design, setting, participants, & measurements

We searched several databases from their date of inception through June 2010 for eligible articles published in any language. We included any study that reported maternal or fetal outcomes in at least five pregnant women in each group with or without CKD. We excluded pregnant women with a history of transplantation or maintenance dialysis.

Results

We identified 13 studies. Adverse maternal events including gestational hypertension, pre-eclampsia, eclampsia, and maternal mortality were reported in 12 studies. There were 312 adverse maternal events among 2682 pregnancies in women with CKD (weighted average of 11.5%) compared with 500 events in 26,149 pregnancies in normal healthy women (weighted average of 2%). One or more adverse fetal outcomes such as premature births, intrauterine growth restriction, small for gestational age, neonatal mortality, stillbirths, and low birth weight were reported in nine of the included studies. Overall, the risk of developing an adverse fetal outcome was at least two times higher among women with CKD compared with those without.

Conclusions

This review summarizes current available evidence to guide physicians in their decision-making, advice, and care for pregnant women with CKD. Additional studies are needed to better characterize the risks.     

Attitudes toward menopause in HIV-infected and at-risk women

Objective

To study attitudes toward menopause in women with or at risk of human immunodeficiency virus (HIV) aged 35 to 60 in New York City, NY, USA.

Design

Data were obtained at the baseline interview in a cohort study of menopause. Of 502 participating women, 92 were postmenopausal and 162 were perimenopausal.

Results

Overall, 37.5% of women had a relatively favorable attitude toward menopause. African Americans had a 72% greater odds of a positive attitude (OR = 1.72, 95% CI 1.16–2.57) than all other groups after adjusting for covariates. Hispanic women had the least favorable view of menopause. Experience of >3 menopausal symptoms and negative life events—being a witness to a murder, and the death of a child—were significantly associated with negative attitudes towards menopause (OR = 0.62, 95% CI 0.42–0.93 and OR = 0.64, 95% CI 0.43–0.93, respectively). Depressive symptoms, street drug use, and having a domestic partner, which is significant in single variable analyses, did not remain independent predictors in multivariate results. HIV status, menopause status, and age at interview were not associated with menopause attitudes.

Conclusions

HIV-infected, drug-using, low-income women showed generally unfavorable attitudes towards menopause. High stress life events coupled with a high prevalence of depressive symptoms indicate this population has special needs marked by the menopause transition into older age.     

Gestational diabetes and adverse perinatal outcomes from 716,152 births in France in 2012

Aims/hypothesis

The aim of this study was to assess the risk of adverse perinatal outcomes in gestational diabetes mellitus (GDM) in a large national cohort.

Methods

All deliveries taking place after 22 weeks in France in 2012 were included by extracting data from the hospital discharge database and the national health insurance system. The diabetic status of mothers was determined by the use of glucose-lowering agents and by hospital diagnosis. Outcomes were analysed according to the type of diabetes and, in the GDM group, whether or not diabetes was insulin-treated.

Results

The cohort of 796,346 deliveries involved 57,629 (7.24%) mothers with GDM. Mother–infant linkage was obtained for 705,198 deliveries. The risks of adverse outcomes were much lower with GDM than with pregestational diabetes. After limiting the analysis to deliveries after 28 weeks to reduce immortal time bias, the risks of preterm birth (OR 1.3 [95% CI 1.3, 1.4]), Caesarean section (OR 1.4 [95% CI 1.4, 1.4]), pre-eclampsia/eclampsia (OR 1.7 [95% CI 1.6, 1.7]), macrosomia (OR 1.8 [95% CI 1.7, 1.8]), respiratory distress (OR 1.1 [95% CI 1.0, 1.3]), birth trauma (OR 1.3 [95% CI 1.1, 1.5]) and cardiac malformations (OR 1.3 [95% CI 1.1, 1.4]) were increased in women with GDM compared with the non-diabetic population. Higher risks were observed in women with insulin-treated GDM than those with diet-treated GDM. After limiting the analysis to term deliveries, an increased risk of perinatal mortality was observed. After excluding women suspected to have undiagnosed pregestational diabetes, the risk remained moderately increased only for those with diet-treated GDM (OR 1.3 [95% CI 1.0, 1.6]).

Conclusions/interpretation

GDM is associated with a moderately increased risk of adverse perinatal outcomes, which is higher in insulin-treated GDM than in non-insulin-treated GDM for most outcomes.

     

Elevated Blood Pressure and Obesity in Childhood: A Cross-Sectional Evaluation of 4,609 Schoolchildren

Background:

The incidence of obesity in children is increasing worldwide, primarily in urbanized, high-income countries, and hypertension development is a detrimental effect of this phenomenon.

Objective:

In this cross-sectional study, we evaluated the prevalence of excess weight and its association with high blood pressure (BP) in schoolchildren.

Methods:

Here 4,609 male and female children, aged 6 to 11 years, from 24 public and private schools in Maringa, Brazil, were evaluated. Nutritional status was assessed by body mass index (BMI) according to cutoff points adjusted for sex and age. Blood pressure (BP) levels above 90th percentile for gender, age and height percentile were considered elevated.

Results:

The prevalence of excess weight among the schoolchildren was 24.5%; 16.9% were overweight, and 7.6% were obese. Sex and socioeconomic characteristics were not associated with elevated BP. In all age groups, systolic and diastolic BP correlated with BMI and waist and hip measurements, but not with waist-hip ratio. The prevalence of elevated BP was 11.2% in eutrophic children, 20.6% in overweight children [odds ratio (OR), 1.99; 95% confidence interval (CI), 1.61-2.45], and 39.7% in obese children (OR, 5.4; 95% CI, 4.23-6.89).

Conclusion:

Obese and overweight children had a higher prevalence of elevated BP than normal-weight children. Our data confirm that the growing worldwide epidemic of excess weight and elevated BP in schoolchildren may also be ongoing in Brazil.     

The association between psoriasis and obesity: a systematic review and meta-analysis of observational studies

Objective:

Psoriasis is an inflammatory skin disease affecting 2–4% of the world population. The objective of this study was to perform a systematic review and meta-analysis synthesizing the epidemiological associations between psoriasis and obesity.

Data sources:

We searched for observational studies from MEDLINE, EMBASE and Cochrane Central Register from 1 January 1980 to 1 January 2012. We applied the Meta-Analysis of Observational Studies in Epidemiology guidelines in the conduct of this study.

Study selection:

We identified 16 observational studies with a total of 2.1 million study participants (201 831 psoriasis patients) fulfilling the inclusion criteria.

Results:

Using random-effects meta-analysis, the pooled odds ratio (OR) for obesity among patients with psoriasis was 1.66 (95% confidence interval (CI) 1.46–1.89) compared with those without psoriasis. From the studies that reported psoriasis severity, the pooled OR for obesity among patients with mild psoriasis was 1.46 (95% CI 1.17–1.82) and the pooled OR for patients with severe psoriasis was 2.23 (95% CI 1.63–3.05). One incidence study found that psoriasis patients have a hazard ratio of 1.18 (95% CI 1.14–1.23) for new-onset obesity.

Conclusions:

Overall, compared with the general population, psoriasis patients have higher prevalence and incidence of obesity. Patients with severe psoriasis have greater odds of obesity than those with mild psoriasis.     

Paroxysmal nocturnal hemoglobinuria and pregnancy before the eculizumab era: the French experience

Background

Pregnancy in women with paroxysmal nocturnal hemoglobinuria is rare, with few reports on maternal and fetal mortality rates.

Design and Methods

A specific questionnaire designed to solicit data on pregnancies in women with paroxysmal nocturnal hemoglobinuria was sent to all members of the French Society of Hematology in January 2008.

Results

We identified 27 pregnancies in 22 women at 10 French Society of Hematology centers between 1978 and 2008. The median age was 21.5 years at diagnosis of paroxysmal nocturnal hemoglobinuria and 27 years at pregnancy. None of these women had received eculizumab during their pregnancy. Maternal complications, consisting mostly of cytopenias requiring transfusions, occurred in 95% of cases. Two cases of severe aplastic anemia (de novo in one case and relapse in the other) were recorded. No thrombotic events occurred during pregnancy, whereas 4 postpartum thromboses (16%) were recorded, 2 of which were fatal (maternal mortality rate 8%). Most patients received antithrombotic prophylaxis during pregnancy and postpartum (n=16; 64%). Delivery was preterm in 29% of cases, and birth weight was less than 3 kg in 53% of cases. Fetal mortality rate was 4%.

Conclusions

Pregnancy during paroxysmal nocturnal hemoglobinuria is associated with increased maternal and fetal mortality rates (8% and 4%, respectively, in this series). Maternal mortality is related to postpartum thromboses. Prophylactic anticoagulation is recommended during pregnancy and for six weeks postpartum.     

Infant Mortality in Novo Hamburgo: Associated Factors and Cardiovascular Causes

Background

Infant mortality has decreased in Brazil, but remains high as compared to that of other developing countries. In 2010, the Rio Grande do Sul state had the lowest infant mortality rate in Brazil. However, the municipality of Novo Hamburgo had the highest infant mortality rate in the Porto Alegre metropolitan region.

Objective

To describe the causes of infant mortality in the municipality of Novo Hamburgo from 2007 to 2010, identifying which causes were related to heart diseases and if they were diagnosed in the prenatal period, and to assess the access to healthcare services.

Methods

This study assessed infants of the municipality of Novo Hamburgo, who died, and whose data were collected from the infant death investigation records.

Results

Of the 157 deaths in that period, 35.3% were reducible through diagnosis and early treatment, 25% were reducible through partnership with other sectors, 19.2% were non-preventable, 11.5% were reducible by means of appropriate pregnancy monitoring, 5.1% were reducible through appropriate delivery care, and 3.8% were ill defined. The major cause of death related to heart disease (13.4%), which was significantly associated with the variables ‘age at death’, ‘gestational age’ and ‘birth weight’. Regarding access to healthcare services, 60.9% of the pregnant women had a maximum of six prenatal visits.

Conclusion

It is mandatory to enhance prenatal care and newborn care at hospitals and basic healthcare units to prevent infant mortality.