Colchicine--what is its place in the management of acute gout?

This series of articles facilitated by the Cochrane Musculoskeletal Group (CMSG) aims to place the findings of recent Cochrane musculoskeletal reviews in a context immediately relevant to general practitioners. This article considers the place of colchicine in the management of acute gout.     

Clinical inquiries. What is the most effective management of acute fractures of the base of the fifth metatarsal?

For acute Jones' fractures in recreationally active patients, early intramedullary screw fixation results in lower failure rates and shorter times to both clinical union and return to sports than non-weightbearing short leg casting (strength of recommendation [SOR]: A, based on 2 randomized controlled trials [RCT]). Non-weightbearing short leg casting achieves union in 56% to 100% of patients but can require prolonged casting (SOR: B, based on 2 prospective cohorts and multiple retrospective, follow-up studies). Stress fractures were not included in this review. For avulsion fractures of the fifth metatarsal tuberosity, a soft Jones' dressing allows earlier return to pre-injury levels of activity than rigid short leg casting (SOR: B, based on a lower-quality RCT).     

How safe is motherhood in India?

Strategies for reducing maternal mortality in India are suggested for prioritizing maternal and child health (MCH) nationally, for including MCH within welfare services, and for integrating vertical programs into MCH. Attention should be directed to delivery practices and facilities, which account for most of maternal mortality. Clean and well-equipped labor huts which provide quality care should be available in each community. High-risk patients should be housed in maternity waiting homes located near hospitals. Improvements should be made in provision of quality prenatal care in villages, primary health care, and evaluation of services. A focus on family planning targets is not sufficient. Postpartum care programs should function as centers for family activities. A national blood transfusion network should be examined as a feasible plan. All government vehicles should be at the disposal of emergency situations. Home science books for prospective mothers should include chapters on pregnancy, childbirth, and care of the newborn. Television serials hold promise as useful tools for mass health education. Medical students in Departments of Gynecology and Obstetrics should spend 66% of their training time in obstetrics and practical skills in childbirth and newborn care. Regional centers for research and evaluation should be established by the Council on Medical Research. The right to safe motherhood should be assured. A nationwide study conducted in the late 1970s found that maternal mortality was 753/100,000 deliveries. A hospital-based study in 1982-83 found that there were 133 maternal deaths/32,812 deliveries, a maternal mortality rate of 405/100,000 live births. 58.8% of maternal deaths were attributed to obstetric causes: 12.8% to hemorrhage, 17.3% to infection, 12% to hypertensive disorders, 8.3% to ruptured uterus. An additional 15.8% of deaths were caused by hepatitis and 7.5% by anemia. Indian maternal mortality in one week equals the total maternal mortality in all of Europe in one year.     

A critical appraisal of guidelines used for management of severe acute malnutrition in South Africa’s referral system

Background

Focusing on healthcare referral processes for children with severe acute malnutrition (SAM) in South Africa, this paper discusses the comprehensiveness of documents (global and national) that guide the country’s SAM healthcare. This research is relevant because South African studies on SAM mostly examine the implementation of WHO guidelines in hospitals, making their technical relevance to the country’s lower level and referral healthcare system under-explored.

Methods

To add to both literature and methods for studying SAM healthcare, we critically appraised four child healthcare guidelines (global and national) and conducted complementary expert interviews (n = 5). Combining both methods enabled us to examine the comprehensiveness of the documents as related to guiding SAM healthcare within the country’s referral system as well as the credibility (rigour and stakeholder representation) of the guideline documents’ development process.

Results

None of the guidelines appraised covered all steps of SAM referrals; however, each addressed certain steps thoroughly, apart from transit care. Our study also revealed that national documents were mostly modelled after WHO guidelines but were not explicitly adapted to local context. Furthermore, we found most guidelines’ formulation processes to be unclear and stakeholder involvement in the process to be minimal.

Conclusion

In adapting guidelines for management of SAM in South Africa, it is important that local context applicability is taken into consideration. In doing this, wider stakeholder involvement is essential; this is important because factors that affect SAM management go beyond in-hospital care. Community, civil society, medical and administrative involvement during guideline formulation processes will enhance acceptability and adherence to the guidelines.

     

How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence

This is an overview of evidence of the effectiveness of antenatal care in relation to maternal mortality and serious morbidity, focused in particular on developing countries. It concentrates on the major causes of maternal mortality, and traces their antecedent morbidities and risk factors in pregnancy. It also includes interventions aimed at preventing, detecting or treating any stage along this pathway during pregnancy. This is an updated and expanded version of a review first published by the World Health Organization (WHO) in 1992. The scientific evidence from randomised controlled trials and other types of intervention or observational study on the effectiveness of these interventions is reviewed critically. The sources and quality of available data, and possible biases in their collection or interpretation are considered. As in other areas of maternal health, good-quality evidence is scarce and, just as in many aspects of health care generally, there are interventions in current practice that have not been subjected to rigorous evaluation. A table of antenatal interventions of proven effectiveness in conditions that can lead to maternal mortality or serious morbidity is presented. Interventions for which there is some promising evidence, short of proof, of effectiveness are explored, and the outstanding questions formulated. These are presented in a series of tables with suggestions about the types of study needed to answer them.     

How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence

This is an overview of evidence of the effectiveness of antenatal care in relation to maternal mortality and serious morbidity, focused in particular on developing countries. It concentrates on the major causes of maternal mortality, and traces their antecedent morbidities and risk factors in pregnancy. It also includes interventions aimed at preventing, detecting or treating any stage along this pathway during pregnancy. This is an updated and expanded version of a review first published by the World Health Organization (WHO) in 1992. The scientific evidence from randomised controlled trials and other types of intervention or observational study on the effectiveness of these interventions is reviewed critically. The sources and quality of available data, and possible biases in their collection or interpretation are considered. As in other areas of maternal health, good-quality evidence is scarce and, just as in many aspects of health care generally, there are interventions in current practice that have not been subjected to rigorous evaluation. A table of antenatal interventions of proven effectiveness in conditions that can lead to maternal mortality or serious morbidity is presented. Interventions for which there is some promising evidence, short of proof, of effectiveness are explored, and the outstanding questions formulated. These are presented in a series of tables with suggestions about the types of study needed to answer them.     

How has the management of acute coronary syndrome changed in the Russian Federation during the last 10 years?

Methods

We report trends and patterns of percutaneous cardiovascular interventions (PCI) by region for 2005–2009, with more detailed data on management of myocardial infarctions in 2009–2103, relating them to regional economic development and changes in mortality from myocardial infarction.

How effective is your safety culture?

Safety cultures are nothing new. How a company implements its management systems and determines who will drive them will ultimately affect its success.