Sustainable antenatal care services in an urban Indigenous community: the Townsville experience

OBJECTIVE: To evaluate the impact of a sustained, community-based collaborative approach to antenatal care services for Indigenous women. DESIGN: Prospective quality improvement intervention, the Mums and Babies program, in a cohort of women attending Townsville Aboriginal and Islanders Health Service, 1 January 2000 - 31 December 2005 (MB group), compared with a historical control group (PreMB group), 1 January 1998 - 30 June 1999. MAIN OUTCOME MEASURES: Proportion of women having inadequate antenatal care and screening; perinatal indicators. RESULTS: The number of antenatal visits per pregnancy increased from three (interquartile range [IQR], two to six) in the PreMB group to six (IQR, four to ten) in the MB group (P < 0.001). There were significant improvements in care planning, completion of cycle-of-care, and antenatal education activities throughout the study period. About 90% of all women attending for antenatal care were screened for sexually transmitted diseases, 89% had measurement of haemoglobin level, and serological tests for hepatitis B and syphilis (minimum antenatal screening). There was increased attendance for dating and morphology scans. In the MB group compared with the PreMB group, there was a significant reduction in perinatal mortality (14 v 60 per 1000 births; P = 0.014). CONCLUSION: Sustained access to a community-based, integrated, shared antenatal service has improved perinatal outcomes among Indigenous women in Townsville.     

女性乳腺炎决定因素的纵向评价

目的:纵向评估生育女性乳腺炎危险因素及金葡菌相关性。方法:前瞻性队列研究346例生育女性乳腺炎及金葡菌临床病情。分别于产前和产后8周共6个时间点问卷调查。收集母亲和婴儿口/鼻棉拭子,产后母乳样本,培养金黄色葡萄球菌。离散多变量风险回归模型(发病率比(IRR))评估乳腺炎风险因素。结果:20%(70/346)的产妇出现乳腺炎。乳头损伤(IRR 2.17,95%CI 1.21-3.91),乳汁过多(IRR 2.60,95%CI 1.58-4.29),使用乳罩(IRR 2.93,95%CI 1.72-5.01)均为乳腺炎高危因素。乳头(IRR 1.72,95%CI 1.04-2.85)或母乳(IRR 1.78,95%CI 1.08-12.92)感染金黄色葡萄球菌也增加乳腺炎风险,但非显著相关。结论:乳头损伤,乳汁过多,乳罩及金黄色葡萄球菌,均增加乳腺炎分风险。减少乳头损伤,有助于减少产妇乳房感染。     

Early discharge and postnatal depression: a prospective cohort study

OBJECTIVES: To determine whether women discharged from hospital < or = 72 hours after childbirth (early discharge) were at greater risk of developing symptoms of postnatal depression during the following six months than those discharged later (late discharge), their reasons for early discharge and their level of postnatal support. DESIGN AND SETTING: Population-based, prospective cohort study with questionnaires at Day 4, and at 8, 16 and 24 weeks postpartum, conducted at all birth sites in the Australian Capital Territory (ACT). PARTICIPANTS: Women resident in the ACT giving birth to a live baby from March to October 1997. MAIN OUTCOME MEASURE: A score > 12 on the Edinburgh Postnatal Depression Scale (EPDS). RESULTS: 1295 (70%) women consented to participate; 1193 (92%) were retained in the study to 24 weeks and, of these, 1182 returned all four questionnaires. Of the 1266 women for whom length-of-stay data were available, 467 (37%) were discharged early and 799 (63%) were discharged late. There were no significant differences between the proportion of women discharged early who ever scored > 12 on the EPDS during the six postpartum months and those discharged late (17% v. 20%), even after controlling for other risk factors (adjusted OR, 0.67; 95% CI, 0.44-1.01). Of women discharged early, 93% had at least one postnatal visit at home from a midwife and 81% were "very satisfied" with the care provided. Most women (96%) reported they had someone to help in practical ways. CONCLUSIONS: Women discharged early after childbirth do not have an increased risk of developing symptoms of postnatal depression during the following six months.     

代谢正常肥胖转归糖尿病风险的前瞻性队列研究

目的  了解泸州社区40岁以上代谢正常肥胖（MHO）患病率及随访3年糖尿病发病率情况。 方法  2011年4月-2011年8月采用多级整群抽样方法,对泸州市3个社区不同街道40岁以上非糖尿病居民进行问卷调查、体格检查和生化检测,于2014年6月-2014年10月对其进行随访调查。结果  共计纳入2 442例人群（男性30.7%）。MHO、代谢正常非肥胖（MHNO）、代谢异常肥胖（MUHO）及代谢异常非肥胖（MUHNO）分别占14.8%、45.3%、19.5%和20.4%,男、女MHO患病率分别为11.2%和15.4%。随访3年,共计248例转归为糖尿病,与MHNO比较,MHO、MUHO及MUHNO糖尿病发病风险分别是MHNO的1.64（95%CI：0.99,2.70）,5.23（95%CI：3.72,7.36）及3.93（95%CI：2.74,5.64）倍,女性MHO糖尿病发病风险是MHNO的2.05（95%CI：1.15,3.65）倍。MHO组随访3年后TG、SBP、DBP、FBS和OGTT 2 h血糖指标异常百分比分别为34.3%、39.4%、22.6%、8.3%及43.4%,与MHNO组比较明显增加（P <0.05）。结论  ①MHO在女性和相对低龄的人群中患病率更高;②MHO组糖尿病发病率明显低于MUHO、MUHNO组,女性MHO组糖尿病发病率高于MHNO组;③与MHNO比较,MHO更易发生代谢异常。

     

基于前瞻性队列研究体外受精-胚胎移植对不良妊娠结局的影响

目的：评价体外受精-胚胎移植(in vitro fertilization-embryo transfer,IVF-ET)技术本身是否会增加子代不良妊 娠结局(adverse pregnancy outcomes,APOs)的风险。方法：选择诊断为不孕症通过IVF-ET受孕的妇女为暴露组,诊断为 不孕症但通过非辅助生殖技术治疗(如促排卵或简单药物治疗)后自然怀孕的妇女作为非暴露组,建立前瞻性队列。 通过单因素分析找出两组除IVF-ET操作因素外存在差异的因素,再采用多因素logistic回归分析控制这些因素,分析 IVF-ET技术对APOs的独立作用。结果：多因素logistic回归分析显示,在控制混杂因素后,IVF-ET受孕孕妇较诊断为 不孕症但自然受孕孕妇显著增加早产(OR=1.28,95% CI：1.05~1.56)、低出生体重(OR=1.69,95% CI：1.27~2.31)、围 生期死亡(OR=5.33,95% CI：2.44~11.81)和先天畸形(OR=1.83,95% CI：1.12~2.94)的风险。结论：IVF-ET操作因素本 身可能会增加APOs的风险。     

女性肾功能与心血管疾病及死亡危险之间的关系：一项前瞻队列研究

最近一项美国研究在相对健康的女性中，评价了肾功能与心血管疾病及死亡危险之间的关系。     

Life situations and the care burden for stroke patients and their informal caregivers in a prospective cohort study

Background. The purpose of this study was to analyse whether the parallel life situation between stroke patients and their informal caregivers (dyads) shown in cross-sectional studies prevails also in a longitudinal perspective.Methods. A total of 377 Swedish stroke patients, aged ≥65 years, and their 268 informal caregivers were followed from hospital admission and one year on. Analyses were based on patient interviews, functional ability (MMSE) score, Nottingham Health Profile (NHP) score, Hospital Anxiety and Depression (HAD) score, self-rated health score, and the Gothenburg Quality of Life (GQL) activity score. Similar information was obtained by postal questionnaires from informal caregivers, also including information on the nature and amount of assistance provided and on Caregiver Burden (CB) score.Results. Before index admission informal caregivers provided care on average 5 h per week and after discharge 11 h per week (P < 0.0001). Support volume was associated with patient sex (more for men), low patient’s functional ability, low received municipal social service support, closeness of patient–caregiver relation, and short distance to patient’s home. Significant positive associations within the dyads were found for HAD anxiety score (P < 0.0001), total NHP score (P < 0.0001), and GQL activity score (P < 0.0001) after adjustment for patient’s age, sex, functional ability, and patient–caregiver relationship. CB score increased with amount of informal caregiver support, patient’s age, and with low functional ability and low amount of municipal social service support. All these associations were constant across time.Conclusions. There was an association within the dyads regarding anxiety score, NHP score, and activity score. CB score was generally high.     

Life situations and the care burden for stroke patients and their informal caregivers in a prospective cohort study

Abstract

Background. The purpose of this study was to analyse whether the parallel life situation between stroke patients and their informal caregivers (dyads) shown in cross-sectional studies prevails also in a longitudinal perspective.

Methods. A total of 377 Swedish stroke patients, aged ≥65 years, and their 268 informal caregivers were followed from hospital admission and one year on. Analyses were based on patient interviews, functional ability (MMSE) score, Nottingham Health Profile (NHP) score, Hospital Anxiety and Depression (HAD) score, self-rated health score, and the Gothenburg Quality of Life (GQL) activity score. Similar information was obtained by postal questionnaires from informal caregivers, also including information on the nature and amount of assistance provided and on Caregiver Burden (CB) score.

Results. Before index admission informal caregivers provided care on average 5 h per week and after discharge 11 h per week (P < 0.0001). Support volume was associated with patient sex (more for men), low patient’s functional ability, low received municipal social service support, closeness of patient–caregiver relation, and short distance to patient’s home. Significant positive associations within the dyads were found for HAD anxiety score (P < 0.0001), total NHP score (P < 0.0001), and GQL activity score (P < 0.0001) after adjustment for patient’s age, sex, functional ability, and patient–caregiver relationship. CB score increased with amount of informal caregiver support, patient’s age, and with low functional ability and low amount of municipal social service support. All these associations were constant across time.

Conclusions. There was an association within the dyads regarding anxiety score, NHP score, and activity score. CB score was generally high.     

应用队列研究方法检验饮酒与肠癌发病的联系

目的:了解饮酒者与非饮酒者人群中肠癌发病情况,验证饮酒与肠癌发病之间的关系.方法:以1989年5月-1990年4月期间,参加浙江省嘉善县肠癌筛检的10个乡镇30岁及以上人口共64 102人为研究队列,其中29 044名饮酒者为暴露组,其余为非暴露组.随访时间为1990年5月1日至2001年12月1日,观察队列的肠癌发病情况,应用Cox回归模型计算两者的相对危险度(RR).结果:全队列64 102人,共观察658 100.24人年.暴露组29 044人,随访298 497.23人年;非暴露组35 328人,随访359 603.01人年.全队列中合计肠癌新发病例242例,其中暴露组新发病例108例,发病密度为36.18/10万,非暴露组新发134例,发病密度为37.26/10万,两者相比无显著性差异(Z＝0.52,P>0.05);饮酒与肠癌发病的粗RR值为0.97(95%CI为0.75～1.25),调整RR值为1.13(95%CI为0.87～1.48)无统计学显著意义.经计算,本研究的检验效能(1-β)为96.99%.结论:在嘉善县人群中,饮酒不是肠癌的危险因素.     

环境烟草烟雾与从不吸烟的中国妇女的死亡率：前瞻性队列研究

目的：评价源自丈夫、工作场所以及生命早期家庭成员的环境烟草烟雾暴露与中国妇女全死因、恶性肿瘤或心血管疾病死亡率的关系。设计：中国上海正在进行的前瞻性队列研究。参加人员：72829名从不吸烟妇女中有65180人提供了其丈夫的吸烟资料，有66520人提供了源自工作场所和生命早期家庭成员的烟草烟雾暴露资料。主要的评价结果指标：全死因死亡率以及恶性肿瘤、心血管疾病死亡专率。按暴露状况分层的累积死亡率以及风险比。结果：源自丈夫的烟草烟雾暴露（主要是现时暴露）与全死因死亡率增加有显著联系，风险比（HR）为1．15，95％可信区间为1.01～1．31，与心血管疾病死亡率增加也有联系（1、37，1．06～1．78）。源自工作场所的烟草烟雾暴露与恶性肿瘤死亡率增加有联系（1、19，0．94～1．50），特别是肺癌（1．79，1．09～2．93）。生命早期暴露与心血管疾病死亡率增加有联系（1．26，0．94～1．69）。结论：在中国妇女中环境烟草烟雾暴露与全死因死亡率以及肺癌和心血管疾病死亡率的中等度增加有关。     

Placental location,postpartum hemorrhage and retained placenta in women with a previous cesarean section delivery: a prospective cohort study

Objective: Women previously giving birth with cesarean section have an increased risk of postpartum hemorrhage (PPH) and retained placenta. The objective of this study was to determine if anterior placental location increased the risk of PPH and retained placenta in such women.

Materials and methods: We performed a prospective cohort study on 400 women with cesarean section delivery in a previous pregnancy. Ultrasound examinations were performed at gestational week 28–30, and placental location, myometrial thickness, and three-dimensional vascularization index (VI) were recorded. Data on maternal age, parity, BMI, smoking, gestational week at delivery, induction, delivery mode, oxytocin, preeclampsia, PPH, retained placenta, and birth weight were obtained for all women. Outcome measures were PPH (≥1,000?mL) and retained placenta.

Results: The overall incidence of PPH was 11.0% and of retained placenta 3.5%. Twenty-three women (11.8%) with anterior placenta had PPH compared to 12 (6.9%) with posterior or fundal locations. The odds ratio was 1.94, but it did not reach statistical significance. There was no significant risk increase for retained placenta in women with anterior placentae. Seven of eight women with placenta previa had PPH, and four had retained placenta.

Conclusions: The overall risk of PPH and retained placenta was high for women with previous cesarean section. Anterior location of the placenta in such women tended to impose an increased risk for PPH but no risk increase of retained placenta. Placenta previa in women with previous cesarean section is associated with a high risk for PPH and retained placenta.     

Survival of Indigenous and non-Indigenous Queenslanders after a diagnosis of lung cancer: a matched cohort study

OBJECTIVE: To compare survival of Indigenous and non-Indigenous lung cancer patients and to investigate any corresponding differences in stage, treatment and comorbidities. DESIGN AND SETTING: Cohort study of 158 Indigenous and 152 non-Indigenous patients (frequency-matched on age, sex and rurality) diagnosed with lung cancer between 1996 and 2002 and treated in Queensland public hospitals. MAIN OUTCOME MEASURES: Survival after diagnosis of lung cancer; effects of stage at diagnosis, treatment, comorbidities and histological subtype on lung cancer-specific survival. RESULTS: Survival of Indigenous lung cancer patients was significantly lower than that of non-Indigenous patients (median survival, 4.3 v 10.3 months; hazard ratio, 1.48; 95% CI, 1.14-1.92). Of 158 Indigenous patients, 72 (46%) received active treatment with chemotherapy, radiotherapy or surgery compared with 109 (72%) of the 152 non-Indigenous patients, and this treatment disparity remained after adjusting for histological subtype, stage at diagnosis, and comorbidities (adjusted risk ratio, 0.65; 95% CI, 0.53-0.73). The treatment disparity explained most of the survival deficit: the hazard ratio reduced to 1.10 (95% CI, 0.83-1.44) after inclusion of treatment variables in the proportional hazards survival model. The remaining survival deficit was explained by the higher prevalence of comorbidities among Indigenous cancer patients, mainly diabetes. CONCLUSION: Survival after a diagnosis of lung cancer is worse for Indigenous patients than for non-Indigenous patients, and differences in treatment between the two groups are mainly responsible.     

Implementing surviving sepsis campaign bundles in China: a prospective cohort study

Background Surviving sepsis campaign (SSC) bundles have been demonstrated to significantly improve survival in sepsis and septic shock patients worldwide.Compliance with these protocols and resultant m...     

Latrodectism: a prospective cohort study of bites by formally identified redback spiders

OBJECTIVE: To determine the spectrum of severity and early diagnostic predictors of redback spider bites (Latrodectus hasselti), and to examine the effect of intramuscular redback antivenom. DESIGN AND SETTING: Prospective cohort study of calls to New South Wales, Queensland and Western Australian poisons information centres and presentations to Royal Prince Alfred Hospital and Royal Darwin Hospital emergency departments. PATIENTS: 68 people with definite redback spider bites in which the spider was immediately collected and expertly identified (1 February 1999 to 30 April 2002). INTERVENTIONS: Intramuscular redback spider antivenom in a smaller cohort of hospitalised patients. MAIN OUTCOME MEASURES: Pain severity and duration, local effects and systemic envenomation (effects, prevalence, and persistence > 24 hours). RESULTS: The median duration of effects was 48 hours (interquartile range, 24-96 hours). Pain occurred after all bites and was severe in 42 (62%). Forty-five patients (66%) had pain lasting longer than 24 hours, and 22 (32%) were unable to sleep because of pain. Systemic effects occurred in 24 (35%). Increasing pain over one hour occurred in 37 cases (54%), and local/regional diaphoresis in 23 (34%); both these features were highly predictive of L. hasselti bites compared with bites of other spiders. One of six patients treated with intramuscular antivenom (17%) had no pain at 24 hours, compared with two of 17 untreated patients (12%) (difference, 5%; 95% CI, -36% to +64%; P = 0.95). There was no difference in duration of systemic effects with antivenom administration. CONCLUSIONS: Most redback spider bites cause severe and persistent effects. Intramuscular antivenom appears to be less effective than previously thought and its use by this route needs review.