Normal perinatal mortality in type 1 diabetes mellitus in a series of 300 consecutive pregnancy outcomes

Reports of outcomes of pregnancy in women with type 1 diabetes have consistently found increased perinatal mortality and morbidity. The primary objective of our study was to compare the perinatal mortality rate in type 1 diabetic pregnancies with that of the general population. The secondary objective was to compare the morbidities in these groups. A series of 247 women with type 1 diabetes had 300 consecutive pregnancy outcomes analyzed over a 10-year period. They were compared with the control population from the same hospital. Perinatal mortality was 6.6/1000 (95% CI, 0-17), which was significantly lower than the control population rate of 31/1000. There was an increased incidence of morbidity including maternal hypertension, cesarean section, preterm delivery, birth injury, large for gestational age infants, admissions to neonatal intensive care, neonatal hypoglycemia, and phototherapy. Pregnancies in type 1 diabetes can be associated with a normal perinatal mortality rate although morbidity remains elevated compared with controls.     

Does insomnia in prison improve with time? Prospective study among remanded prisoners using the Pittsburgh Sleep Quality Index

Insomnia is a frequent health problem in prison, but little is known about its severity and duration. The objective was to find out whether subjective sleep quality improves during time and which factors influence improvement. Fifty-two randomly chosen prisoners complaining of insomnia at the Geneva remand prison were interviewed (T1) and followed up ten days (T2) and two months (T3) later. They received hypnotics habitually prescribed by prison physicians (benzodiazepines, chloralhydrate, zolpidem). After ten days 40 patients were still in prison and agreed to participate and after two months 16 prisoners could be re-evaluated. Total Pittsburgh Sleep Quality Index (PSQI) scores at T1 were 12.3 +/- 4.7. At T2 and T3, PSQI scores improved significantly, whereas General Health Questionnaire (GHQ) scores and conditions of imprisonment were similar. Only 12.5% of patients at T2, and 6.25% at T3, were 'good sleepers' (PSQI scores =/< 5). Cocaine users and prisoners with a healthy lifestyle reported the greatest improvement of PSQI scores. Our study shows that significant improvement of PSQI scores takes place in the first one to two weeks. However, in spite of regular drug treatment during the following weeks, PSQI scores persisted at a clinically significant level two months later. Drug treatment in prison only partially improves insomnia.     

Depressive symptoms and health-related quality of life: the Heart and Soul Study

Context  Little is known regarding the extent to which patient-reported health status, including symptom burden, physical limitation, and quality of life, is determined by psychosocial vs physiological factors among patients with chronic disease. Objective  To compare the contributions of depressive symptoms and measures of cardiac function to the health status of patients with coronary artery disease. Design, Setting, and Participants  Cross-sectional study of 1024 adults with stable coronary artery disease recruited from outpatient clinics in the San Francisco Bay Area between September 2000 and December 2002. Main Measures  Measurement of depressive symptoms using the Patient Health Questionnaire (PHQ); assessment of cardiac function by measuring left ventricular ejection fraction on echocardiography, exercise capacity on treadmill testing, and ischemia on stress echocardiography; and measurement of a range of health status outcomes, including symptom burden, physical limitation, and quality of life, using the Seattle Angina Questionnaire. Participants were also asked to rate their overall health as excellent, very good, good, fair, or poor. Results  Of the 1024 participants, 201 (20%) had depressive symptoms (PHQ score =" BORDER="0">10). Participants with depressive symptoms were more likely than those without depressive symptoms to report at least mild symptom burden (60% vs 33%; P<.001), mild physical limitation (73% vs 40%; P<.001), mildly diminished quality of life (67% vs 31%; P<.001), and fair or poor overall health (66% vs 30%; P<.001). In multivariate analyses adjusting for measures of cardiac function and other patient characteristics, depressive symptoms were strongly associated with greater symptom burden (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.3-2.7; P = .002), greater physical limitation (OR, 3.1; 95% CI, 2.1-4.6; P<.001), worse quality of life (OR, 3.1; 95% CI, 2.2-4.6; P<.001), and worse overall health (OR, 2.0; 95% CI, 1.3-2.9; P<.001). Although decreased exercise capacity was associated with worse health status, left ventricular ejection fraction and ischemia were not. Conclusions  Among patients with coronary disease, depressive symptoms are strongly associated with patient-reported health status, including symptom burden, physical limitation, quality of life, and overall health. Conversely, 2 traditional measures of cardiac function—ejection fraction and ischemia—are not. Efforts to improve health status should include assessment and treatment of depressive symptoms.      

Discontinuation of antidepressants in newly admitted psychotic patients

Antidepressants may exacerbate manic or psychotic symptoms in vulnerable individuals. The authors discontinued antidepressants in 16 consecutive cases in which patients with manic or psychotic symptoms were otherwise judged to be on a satisfactory regimen prior to admission. Thirteen of the patients improved rapidly, which suggests a possible association between antidepressant discontinuation and clinical improvement in this patient group.     

Case managers' perspectives on critical ingredients of assertive community treatment and on its implementation

OBJECTIVE: The authors sought to identify case managers' perspectives on the critical ingredients, therapeutic mechanisms of action, and gaps in implementation of the critical ingredients of assertive community treatment. METHODS: Seventy-three assertive community treatment teams that attended the 1997 National Assertive Community Treatment Conference rated the degree to which 16 clinical activities were beneficial to clients and rated the importance of 27 possible critical ingredients of the ideal team as well as the extent to which each ingredient characterized their team. RESULTS: At least 50 percent of the teams rated 24 of the 27 critical ingredients as "very important." Having a full-time nurse on the team was rated as the most important ingredient, and medication management was rated as the most beneficial clinical activity. The ratings of teams from urban and rural settings were highly correlated. Critical elements that the teams reported as being the most underimplemented included the presence of a full-time substance abuse specialist, a psychiatrist's involvement on the team, team involvement with hospital discharge, and working with a client support system. CONCLUSIONS: Case managers strongly endorsed the team approach as well as medical aspects of assertive community treatment. Despite broad consensus on the critical ingredients of the ideal assertive community treatment team, several important ingredients appear to be consistently underimplemented.     

Decreasing back stress in home care

Although back injuries are a significant problem in home care, limited information exists regarding which tasks are stressful and how stress can be reduced. This study describes home health aides' perceived stressfulness to the back and provides ideas all home care workers can use to decrease back stress.