From mortality to morbidity: the challenge of the twenty-first century

Although maternal mortality has been the traditional measure used to evaluate the status of women's health in pregnancy, the Division of Reproductive Health at the Centers for Disease Control and Prevention has expanded beyond its surveillance of pregnancy mortality to explore pregnancy morbidity. Working with a variety of partners, we are looking at several questions. What is pregnancy morbidity, its spectrum and prevalence? What are the most serious complications of pregnancy? Are there differences in the severity of complications between white and black women? What conditions should be monitored and by what methods? Answers to these questions should help us understand why some groups of women experience a greater risk of death from pregnancy, but also help us to enlarge the scope of our concern for the health of women before, during, and after pregnancy.     

ERCP术后胰腺炎的预防

ERCP虽然是个相对安全的内镜操作，但它也会有严重甚至致命的并发症。比较多见的有胰腺炎、出血、感染及穿孔，其中以ERCP术后急性胰腺炎（PEP）最常见。发病率为5％左右，其中一部分的PEP是非常凶险的，其死亡率约为0．5％。本文就PEP的预防进行综述，主要涉及药物和支架。     

妊娠糖尿病患者产后家庭护理干预相关研究进展

近年来,随着人们生活水平的提高,妊娠糖尿病及糖耐量异常的患者逐渐增多,并由此引发围产儿死亡率、围产儿患病率增高及产科合并症增多。该文就妊娠糖尿病的发生率、结局、转归以及针对妊娠糖尿病患者产后家庭护理干预措施等进行综述。     

Diabetes in pregnancy: health risks and management

Diabetes in pregnancy is increasing and therefore it is important to raise awareness of the associated health risks to the mother, the growing fetus, and the future child. Perinatal mortality and morbidity is increased in diabetic pregnancies through increased stillbirths and congenital malformation rates. These are mainly the result of early fetal exposure to maternal hyperglycaemia. In the mother, pregnancy may lead to worsening or development of diabetic complications such as retinopathy, nephropathy, and hypoglycaemia. This review defines pregestational and gestational diabetes and the associated health risks to the growing fetus and mother. Management is discussed, focusing on clinical evidence based guidelines published by the American Diabetic Association and the UK National Institute for Health and Clinical Excellence on the management of pregnant women with pre-existing diabetes.     

Pulmonary manifestations of sickle cell disease

Pulmonary complications account for significant morbidity and mortality in patients with sickle cell disease. Clinical lung involvement manifests in two major forms: the acute chest syndrome and sickle cell chronic lung disease. Acute chest syndrome is characterised by fever, chest pain, and appearance of a new infiltrate on chest radiograph. Sickle cell chronic lung disease, on the other hand, manifests as radiographic interstitial abnormalities, impaired pulmonary function, and, in its most severe form, by the evidence of pulmonary hypertension. Progress has been made in understanding the pathophysiology and management of these complications. In this review the current knowledge of the mechanism, diagnosis, and treatment of pulmonary complications of sickle cell disease are discussed.     

STUDY OF LOW BIRTH WEIGHT NEONATES

Low birth weight neonates with 2000g or less birth weight constitute about 10% of live births with perinatal mortality as high as 32.4%. Perinatal morbidity is 19.3% with asphyxia neonatorum and neonatal jaundice heading the list. Epidemiological maternal factors include extremes of age and parity, lack of antenatal care, low socioeconomic status, illiteracy and underweight short women. Etiologic factors are obstetric complications, hypertensive disorders, systemic diseases or idiopathic. The scope of preventive measures include improvement of economic status and education about health and safe pregnancy. Proper antenatal care for early detection of high risk cases, adequate and timely management of complications and adequate facilities for neonatal care can reduce the perinatal morbidity and mortality.KEY WORDS: Low birth weight neonates, Perinatal mortality     

AIDS treatment and maternal mortality in resource-poor countries

The crisis of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS), particularly in resource-poor countries in Africa, Asia, and Latin America, is one of the most devastating pandemics in history and adds a cruel burden on women. High rates of maternal mortality and morbidity continue to take a drastic toll on women worldwide. These health challenges provide a window of opportunity to combine urgent global health needs with women's fundamental right to health care, including targeting resources to provide woman-centered treatment for HIV/AIDS and to avert pregnancy-associated death and morbidity. Governments and organizations have a tremendous responsibility in addressing these health issues. The Global Fund to Fight AIDS, Tuberculosis and Malaria was established last year to make significant funds available for treatment and care. Programs such as MTCT-Plus, which provides treatment for HIV-positive mothers and prevents mother-to-child transmission of HIV, can begin to alleviate the tremendous health burden women bear. Addressing women's health needs and women's right to health care is the essential first step in providing services to millions living with HIV/AIDS and pregnancy-related complications.     

Practical issues in bone mineral density testing

Osteoporotic fractures are a source of morbidity and mortality among postmenopausal women. Clinicians must strive to identify women at risk for osteoporotic fracture and institute proper prophylactic or treatment regimens to decrease the incidence of fractures. The advent of more sensitive, less expensive, and portable bone mineral density assessment techniques, coupled with new strategies for identifying risk factors, has made it easier for clinicians to diagnose this debilitating disease before a fracture occurs. The hope is that bone mineral density testing will result in the early identification of women at risk for osteoporosis, thereby reducing the incidence of osteoporotic fractures.     

Expectant management of severe preeclampsia presenting before 25 weeks of gestation.

BACKGROUND: The treatment of preeclampsia before 25 weeks of gestation remains controversial. The aim was to evaluate the outcome of expectant management of preeclamptic women presenting prior to 25 weeks of gestation. MATERIAL/METHODS: During a five-year period, 55 women presenting with severe preeclampsia at or before 24 weeks and 6 days of gestation were admitted to a high-care unit for expectant management. Indications for delivery were the development of severe maternal morbidity secondary to preeclampsia. Complications were identified from individual patient and infant records. RESULTS: Mean prolongation of gestation was 4.8+/-4.1 days (range: 1-13 days) and the mean maternal hospitalization period was 10.0+/-8.3 days (range: 2-31 days). Conservative management was associated with a 94.5% (52/55) intrauterine fetal loss rate. Of the three live-born infants, one died secondary to respiratory distress syndrome followed by neonatal sepsis and the other two survived with cognitive and motor developmental delay. HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome was diagnosed in 12 women (21.8%). Nine women (16.3%) required transfusions with blood or blood products. There was 1 case (1.8%) of eclampsia. Overall, 15 women (27.2%) had developed some maternal morbidity without any significant differences between <23 weeks' and >/=23 weeks' gestation. Nulliparity was not associated with stillbirth (p=0.8), HELLP syndrome (p=0.8), or overall maternal morbidity (p=0.7). None of the women died or required any long-term treatment. CONCLUSIONS: Conservative management of severe preeclampsia before 25 weeks of gestation is associated with considerable perinatal mortality and morbidity. Maternal complications are relatively common, but generally short-lived.     

老年人重症急性胰腺炎的临床特点与治疗探讨

目的:探讨老年人重症急性胰腺炎(SAP)的临床特点与治疗对策。方法:回顾性分析我院1993年至2004年间收治的45例≥60岁SAP患者的治疗方法,并发症和死亡率。结果:本组并发症发生率为73.3%,常见并发症为休克(51.1%)、ARDS(40.0%)、肾功能不全(35.1%),病死率为51.1%。SAP I级患者早期非手术治疗与早期手术治疗的并发症发生率发病为50.0%和84.6%(p<0.05),病死率分别为25.0%和61.5%(p<0.05)。结论:老年人SAP并发症发生率及死亡率高,对SAP I级患者应尽量采取早期非手术治疗为主,如确需手术治疗,术中和术后因采用合理的治疗措施,以减少术后并发症,降低手术死亡率。     

Eclampsia in Kelantan

A review of eclampsia in Kelantan was undertaken from 1983-1988. There were 146 documented cases in the state (66 per 100,000 deliveries). Eight maternal deaths occurred. Sixty seven (45.9%) were primigravida. Six of the 79 multiparous women developed eclampsia for the first time following remarriages to new partners. The multisystem dysfunction resulting from eclampsia resulted in varied maternal complications. Fatal cerebral haemorrhage (3 cases), acute pulmonary oedema (8 cases), acute renal failure (6 cases), HELLP Syndrome (8 cases) and acute abruptio placentae were the commoner complications. The average number of convulsions per patient was 1.3. The mean gestation of mothers who delivered prematurely (28.2%) was 34.6 weeks and that for those at term (71.8%) was 39.1 weeks. The caesarean section rate was 42.5%. The perinatal mortality rate was 185.9 per 1000. The implications of this high maternal and fetal mortality and morbidity are discussed in the light of the health delivery system and patient education. A team approach to medical management of eclampsia with the need for intensive care monitoring is suggested.     

Psychiatric morbidity in patients with life-threatening asthma: initial report of a controlled study

Thirteen patients who have suffered a "near-miss" death of asthma have been compared to 36 patients with asthma who had not experienced such an episode. Contrary to expectations, there were no differences between the groups in their levels of psychiatric morbidity, their degree of life-style and social restrictions or in their levels of compliance with prescribed medication. However, both groups did show higher than expected levels of psychiatric morbidity, severe life-style and social restrictions and an unexpectedly-high compliance with prescribed medication. The main psychiatric diagnoses that were noted were anxiety disorders. It is concluded that more comprehensive asthma education and close medical follow-up are likely to improve the physical and psychological health of asthmatic patients. The high-risk patients in this study who received such follow-up have shown hospital-admission rates that have been reduced by a half while maintaining good asthma control. This South Australian longitudinal study is continuing.     

Safe Motherhood Act for Research and Treatment

Despite the overall progress in women's health research during the last decade, maternal morbidity and mortality remain understudied. The maternal mortality rate in the United States has not decreased in 20 years, and there is an unacceptable gap in maternal mortality between black and white women. The Safe Motherhood Act for Research and Treatment (SMART Mom Act) was introduced in Congress to address this issue and will focus on research and data collection, safe medications, and education.     

Diarrheal diseases in the history of public health

While the public health threat of HIV/AIDS in developing countries has drawn increasing attention from the international community for more than two decades, other health problems such as diarrheal diseases continue to contribute to higher morbidity and mortality rates in much of the developing world. This literature review is an account of both the history and current risks associated with diarrheal diseases.     

急性百草枯中毒的急救体会

目的:通过回顾分析在急救医学科救治的急性百草枯中毒患者,以总结急性百草枯中毒救治中第一时间的处理要点,以及院内救治的用药方法和治疗手段,并对防治肺纤维化及其他严重致死性并发症的方法进行探讨。方法:该科近期收治的急性百草枯中毒患者14例,其中男4例,女10例,年龄12~65岁,平均年龄为32.6岁。对其早期处理方法、急诊用药方式、方法以及其他治疗手段进行了分析,对其死亡率、救治成功率、严重并发症的发生率、病死率进行总结分析。结果:所有患者均为口服市售20%百草枯溶液而中毒,服毒物剂量约10~100 ml。经抢救治疗,14例患者中死亡12例(85.7%),治愈2例(14.3%);死亡时间为中毒后3~18 d,平均为10.8 d。所有患者均出现不同程度的器官功能损害等并发症,除局部黏膜损伤外,肺纤维化和急性肝、肾功能损害为最常见、严重的并发症,死于上述并发症者分别为12/12、8/10和8/10。结论:百草枯中毒救治成功与否,关键在于服毒后第一时间及时失活和吸附处理。一旦出现肺纤维化,病情基本无法逆转。各种药物对晚期患者的并发症防治和治愈率的提高可能有一定作用。     

急性胰腺炎的分类与严重程度评价进展

急性胰腺炎是胰腺的炎症疾病,其临床表现从轻度自限性到重症胰腺炎,重症胰腺炎导致住院时间延长,高并发症发病率,高死亡率.因此在急性胰腺炎早期做出准确的严重程度评价是十分重要的.各种临床和影像学的评分标准已经运用在急性胰腺炎的评价上.本文将介绍急性胰腺炎的分类以及严重程度评价的进展.     

Understanding maternal mental illness: psychiatric autopsy of a maternal death

Maternal mental illness is a significant public health concern, with established adverse outcomes on both mother and infant, such as impaired mother-infant bonding and infant cognitive and emotional development. In severe cases, maternal mortality and infanticide can tragically occur. This is a report on the suicide of a mother who jumped to her death at three months postpartum. She suffered from puerperal psychosis with bipolar features, with onset at six weeks postpartum. The case highlights the burden of maternal mental illness in our community as well as the need for resources and services to care well for mothers. With a better understanding of its presentation and risk factors, early identification and intervention can reduce morbidity and mortality.     

Use of Six Sigma Methodology to Reduce Appointment Lead-Time in Obstetrics Outpatient Department

This paper focuses on the issue of longer appointment lead-time in the obstetrics outpatient department of a maternal-child hospital in Colombia. Because of extended appointment lead-time, women with high-risk pregnancy could develop severe complications in their health status and put their babies at risk. This problem was detected through a project selection process explained in this article and to solve it, Six Sigma methodology has been used. First, the process was defined through a SIPOC diagram to identify its input and output variables. Second, six sigma performance indicators were calculated to establish the process baseline. Then, a fishbone diagram was used to determine the possible causes of the problem. These causes were validated with the aid of correlation analysis and other statistical tools. Later, improvement strategies were designed to reduce appointment lead-time in this department. Project results evidenced that average appointment lead-time reduced from 6,89 days to 4,08 days and the deviation standard dropped from 1,57 days to 1,24 days. In this way, the hospital will serve pregnant women faster, which represents a risk reduction of perinatal and maternal mortality.     

射频消融治疗胰腺肿瘤安全性的临床研究

目的:探讨射频消融治疗胰腺肿瘤的安全性。方法:回顾性分析2002年1月-2007年12月对78例不能切除胰腺肿瘤的患者行射频消融治疗发生的并发症资料。结果:所有患者均有短期发热症状,部分患者有一过性血清淀粉酶升高,无腹腔出血及腹腔感染发生,胰瘘2例,上消化道出血1例,血管并发症2例,急性重症胰腺炎1例,术后总并发症发生率为7.69%(6/78),其中死亡3例,发生率为3.85%(3/78)。结论:对于不能切除的胰腺肿瘤射频治疗是安全可行的,但由于可能出现致命性严重并发症,必须慎重。     

CD14在脓毒症中的最新进展

脓毒症临床表现多样,是创伤、烧伤、感染、休克等临床危急重患者的常见严重并发症,其发病率和死亡率一直居高不下。前期研究发现,脂多糖结合蛋白(lipopolysaccharide binding protein, LBP)和白细胞分化抗原CD14(Leukocyte differentiation antigen, CD14)通过识别革兰阴性杆菌产生的内毒素,在脓毒症的发病过程中起关键作用。本文通过综合分析CDl4在脓毒症中的致病机理,探讨其在脓毒症诊断及治疗中的潜在临床价值。