Does maternity care improve pregnancy outcomes in women with previous complications? A study from Zimbabwe

To determine the utilization of maternal health care services and pregnancy outcomes for women with a history of complications in previous pregnancy, we analysed the pregnancy records of multiparous women (parity > or =1) who booked and completed follow-up in Gutu district, Zimbabwe between January 1995 and June 1998. Women with previous uncomplicated pregnancies (n = 6140) were classified as low risk, whereas those with complications of previous pregnancy (n = 1077) were classified high risk. At enrolment, there was no difference in maternal age and parity between low- and high-risk women. A higher proportion of high-risk women had more than five antenatal visits (32% versus 21%; P<0.001) and gave birth in hospital (47% versus 18%; P<0.001). The risk of antenatal (relative risk [RR] 1.57; 95% confidence interval [CI] 1.32-1.88), labour/delivery (RR 1.98; 95% CI 1.75-2.25) and neonatal (RR 1.83; 95% CI 1.44-2.34) complications was elevated in high-risk women. There was increased risk for perinatal death in high-risk women, but this did not reach statistical significance (RR 1.56; 95% CI 0.98-2.49). The recurrence ratio for most complications was low and the sensitivity of historical risk markers in predicting women likely to develop further complicated pregnancies was only 23%. Most women with previous pregnancy complications can safely give birth in the rural health centre. We concluded that high-risk women had an elevated risk of complications in the index pregnancy and that better utilization of maternal health care, especially for delivery, reduced adverse perinatal outcomes.     

Does disease management improve clinical and economic outcomes in patients with chronic diseases? A systematic review

PURPOSE: To assess the clinical and economic effects of disease management in patients with chronic diseases. METHODS: Electronic databases were searched for English-language articles from 1987 to 2001. Articles were included if they used a systematic approach to care and evaluated patients with chronic disease, reported objective measurements of the processes or outcomes of care, and employed acceptable experimental or quasi-experimental study designs as defined by the Cochrane Effective Practice and Organization of Care Group. RESULTS: Two reviewers evaluated 16,917 titles and identified 102 studies that met the inclusion criteria. Identified studies represented 11 chronic conditions: depression, diabetes, rheumatoid arthritis, chronic pain, coronary artery disease, asthma, heart failure, back pain, chronic obstructive pulmonary disease, hypertension, and hyperlipidemia. Disease management programs for patients with depression had the highest percentage of comparisons (48% [41/86]) showing substantial improvements in patient care, whereas programs for patients with chronic obstructive pulmonary disease (9% [2/22]) or chronic pain (8% [1/12]) appeared to be the least effective. Of the outcomes more frequently studied, disease management appeared to improve patient satisfaction (71% [12/17]), patient adherence (47% [17/36]), and disease control (45% [33/74]) most commonly and cost-related outcomes least frequently (11% to 16%). CONCLUSION: Disease management programs were associated with marked improvements in many different processes and outcomes of care. Few studies demonstrated a notable reduction in costs. Further research is needed to understand how disease management can most effectively improve the quality and cost of care for patients with chronic diseases.     

Does treatment with calcitriol improve survival in predialysis patients with chronic kidney disease?

Treatment of secondary hyperparathyroidism with activated vitamin D analogs has been associated with improved survival of dialysis-dependent patients with chronic kidney disease (CKD). Whether this treatment regimen affords similar benefits to non-dialysis-dependent patients with CKD remains unclear. In this Practice Point commentary, we discuss a study by Kovesdy et al. that reported enhanced survival in predialysis patients with CKD who received calcitriol for a median duration of 2.1 years. Despite the achievement of favorable results in these patients, the study had several limitations that could preclude generalization of the findings to other populations. These limitations included the nonrandomized, observational design, the small patient population, the exclusive enrollment of men (76.5% of whom were white), and the lack of information on cause of death. Here, we place the findings of the study into clinical context and emphasize the urgent need for large, well-designed, randomized trials that aim to assess cardiovascular and mortality end points.     

Postpartum thyroiditis in women with hypothyroidism antedating pregnancy?

In women with hypothyroidism, levothyroxine (LT) requirements after delivery are assumed to return to prepregnancy values. The occasional observation of discordances prompted this study. Forty-one women (31 receiving LT replacement therapy and 10 receiving suppressive therapy for thyroid carcinoma) were followed during the first year after delivery. A control group of 31 nonpregnant women with hypothyroidism (n = 21) or thyroid carcinoma (n = 10) were also followed during a similar period. Twenty-three patients of 41 (56.1%) had discordant requirements at follow-up after delivery vs. 3 of 31 in the control group (9.7%; P < 0.001). The patterns of discordance in the postdelivery group were hyperthyroidism in 12, increase in LT dose in 5, hyper- and hypothyroidism in 5, and recurrence of Graves' disease in 1 women. Those in the control group were increase in LT dose, hyperthyroidism, and hypo- and hyperthyroidism. The rate of patients with discordant prepregnancy-postpartum LT doses was higher in the noncarcinoma subgroup (67.7% vs. 20.0%; P < 0.01), whereas in the control group, both subgroups displayed a similar rate of discordance (9.5% vs. 10%; P = NS). In conclusion, this study documents that women with hypothyroidism antedating pregnancy display changes in LT requirements in the first year after delivery that suggest postpartum thyroiditis.     

Adverse pregnancy outcomes in women with Behçet’s disease: population-based registry linkage study in Taiwan

Clinical Rheumatology - To estimate the risks of adverse pregnancy outcomes in women with Behçet’s disease (BD) Data collected by the Taiwan National Health Insurance Administration...     

Does weight loss in overweight or obese women improve fertility treatment outcomes? A systematic review

This systematic review assessed the effect of weight loss in overweight and/or obese women undergoing assisted reproductive technology (ART) on their subsequent pregnancy outcome. Weight losses achieved by diet and lifestyle changes, very‐low‐energy diets, non‐surgical medical interventions and bariatric surgery translated into significantly increased pregnancy rates and/or live birth in overweight and/or obese women undergoing ART in 8 of the 11 studies reviewed. In addition, regularization of the menstrual pattern, a decrease in cancellation rates, an increase in the number of embryos available for transfer, a reduction in the number of ART cycles required to achieve pregnancy and a decrease in miscarriage rates were reported. There were also a number of natural conceptions in five of the six studies that reported this outcome. Non‐surgical medical weight loss procedures and bariatric surgery induced the greatest weight losses, but their use, as well as that of very‐low‐energy diets, for weight loss prior to ART requires careful consideration. While the overall quality of the studies included in this review was poor, these results support the clinical recommendation of advising overweight and/or obese women to lose weight prior to ART. Prospective randomized controlled trials are required to establish efficacious evidence‐based guidelines for weight loss interventions in overweight and/or obese women prior to ART treatment.     

Does angina vary with the menstrual cycle in women with premenopausal coronary artery disease?

OBJECTIVE—To determine whether angina in women with established coronary heart disease varies with changes in hormone concentrations during the menstrual cycle.
DESIGN—Subjects were prospectively studied once a week for four weeks.
SETTING—Cardiology outpatient department of tertiary referral centre.
SUBJECTS—Nine premenopausal women, mean (SEM) age 38.89 (2.18) years, with established coronary heart disease, symptomatic angina, and a positive exercise test.
MAIN OUTCOME MEASURE—Myocardial ischaemia as determined by time to 1 mm ST depression during symptom limited exercise testing. Position in the menstrual cycle was established from hormone concentrations.
RESULTS—The early follicular phase, when oestradiol and progesterone concentrations were both low, was associated with the worst exercise performance in terms of time to onset of myocardial ischaemia, at 290 (79) seconds; the best performance (418 (71) seconds) was when oestrogen concentrations were highest in the mid-cycle (p < 0.05). Similar trends were observed in other measured variables. Progesterone concentrations did not influence exercise performance.
CONCLUSIONS—During the menstrual cycle myocardial ischaemia was more easily induced when oestrogen concentrations were low. This may be important for timing the assessment and evaluating treatment in women with coronary heart disease.


Keywords: myocardial ischaemia; exercise testing; oestradiol; progesterone     

Does inhaled albuterol improve diaphragmatic contractility in patients with chronic obstructive pulmonary disease?

We tested the hypothesis that the decrease in dyspnea in patients with COPD with inhaled albuterol is in part due to increased diaphragmatic contractility. Eleven patients with COPD inhaled albuterol or placebo in a double-blind randomized manner. Subsequently, dyspnea was measured while patients breathed through inspiratory resistors, and diaphragmatic contractility was quantified during maximal inspiratory efforts and after twitch stimulation of the phrenic nerves. Albuterol produced a decrease in dyspnea (5 +/- 2 to 4 +/- 2 [SD] Borg units, p < 0.01), and increases in maximal transdiaphragmatic pressure (92.4 +/- 37.2 to 102.8 +/- 37.2 cm H(2)O, p < 0.03) and potentiated twitch transdiaphragmatic pressures (21.6 +/- 7.1 to 25.2 +/- 7.6 cm H(2)O, p < 0.02). The decrease in dyspnea correlated with the increases in maximal and twitch transdiaphragmatic pressures: r = -0.64 (p = 0. 04) and r = -0.65 (p = 0.04), respectively. Compared with placebo, albuterol produced an increase in inspiratory capacity (1.87 +/- 0. 71 to 2.26 +/- 0.74 L, p = 0.002), which accounted for the increases in maximal and twitch transdiaphragmatic pressures. The decrease in dyspnea correlated with the increase in inspiratory capacity (r = -0. 62, p = 0.04), but not with the increase in FEV(1) (r = -0.13, p = 0. 72). In conclusion, albuterol relieves dyspnea and enhances respiratory muscle output in patients with COPD primarily by improving the length-tension relationship of the diaphragm rather than by improving its contractility.     

Does roflumilast improve dyspnea in patients with chronic obstructive pulmonary disease? A meta-analysis

Introduction

Although several large studies showed roflumilast (Rof) has demonstrated efficacy in patients with chronic obstructive pulmonary disease (COPD), the efficacy of Rof in dyspnea remains unclear. We therefore undertook a meta-analysis to assess the efficacy of Rof in dyspnea for COPD patients.

Methods

A computerized search through electronic databases was performed to obtain randomized controlled trials (RCTs). Dyspnea was assessed by the transition dyspnea index (TDI) and the UCSD Shortness of Breath Questionnaire (SOBQ). The quality of the included studies was assessed by the Jadad score. Weighted mean differences (WMDs) and 95% confidence intervals (CIs) were calculated and heterogeneity was assessed with the I² test. The effect sizes were compared with the minimum clinically important difference (MCID).

Results

Four RCTs involving 4,767 patients with forced expiratory volume in one second (FEV₁) <80% predicted met the inclusion criteria. The Jadad score of each study was 5 scores. Rof statistically improved the TDI focal score (WMD =0.30 units; 95% CI: 0.14-0.46), but failed to decrease the SOBQ (WMD =–1.10 units; 95% CI: –4.24 to 2.04). The overall effect sizes were lower than the MCID of the TDI and the SOBQ, respectively.

Conclusions

Sufficient evidence to support Rof relieving dyspnea in COPD patients is currently lacking. Further studies are needed to investigate the effects of Rof in dyspnea, especially for COPD patients with a different phenotype.KEY WORDS : Chronic obstructive pulmonary disease (COPD), roflumilast (Rof), dyspnea, meta-analysis