A cluster randomized controlled trial to evaluate the effectiveness of the clinically integrated RHL evidence -based medicine course

Objective

to develop and validate a questionnaire on severe maternal morbidity and to evaluate the maternal recall of complications related to pregnancy and childbirth. Design: validity of a questionnaire as diagnostic instrument. Setting: a third level referral maternity in Campinas, Brazil. Population: 386 survivors of severe maternal complications and 123 women that delivered without major complications between 2002 and 2007.

Methods

eligible women were traced and interviewed by telephone on the occurrence of obstetric complications and events related to their treatment. Their answers were compared with their medical records as gold standard. Sensitivity, specificity and likelihood ratios plus their correspondent 95% confidence intervals were used as main estimators of accuracy. Main outcomes: diagnosis of severe maternal morbidity associated with past pregnancies, including hemorrhage, eclampsia, infections, jaundice and related procedures (hysterectomy, admission to ICU, blood transfusion, laparotomy, inter-hospital transfer, mechanical ventilation and post partum stay above seven days).

Results

Women did not recall accurately the occurrence of obstetric complications, especially hemorrhage and infection. The likelihood ratios were < 5 for hemorrhage and infection, while for eclampsia it almost reached 10. The information recalled by women regarding hysterectomy, intensive care unit admission and blood transfusion were found to be highly correlated with finding evidence of the event in the medical records (likelihood ratios ranging from 12.7-240). The higher length of time between delivery and interview was associated with poor recall.

Conclusion

Process indicators are better recalled by women than obstetric complication and should be considered when applying a questionnaire on severe maternal morbidity.     

Underlying medical conditions

More than half of maternal deaths in the UK are due to pre-existing medical conditions, and medical emergencies often mimic acute obstetric conditions. An acute flare of systemic lupus erythaematosus, a thyroid storm or a phaeochromocytoma have many of the signs and symptoms of imminent eclampsia. Similarly, severe postpartum haemorrhage can result in diagnostic difficulties of medical conditions such as Addison's syndrome or acute renal failure. An acute collapse can be due to a pulmonary embolus, myocardial infarction, tachyarrhythmia or myasthenia gravis. These conditions are rare; however, unless they are considered in a differential diagnosis, they will not be diagnosed, to the detriment of the woman and her infant. This chapter deals with acute medical conditions occurring uncommonly in pregnant women. An obstetrician should know the initial steps to take in the emergency management of these cases.     

罗格列酮单用或者与阿伐他汀联合使用对于2型糖尿病患者心血管疾病的非传统标志物的作用

背景和目的:罗格列酮与阿伐他汀联合疗法已经被证实对于2型糖尿病患者的血糖控制以及脂质水平都有益处。本试验将通过检测罗格列酮与阿伐他汀联合疗法对于2型糖尿病患者的生物标记水平的作用来研究该联合疗法对血管炎的作用。方法:30例患有2型糖尿病和高脂血症的患者被纳入治疗。对这些患者给予罗格列酮单一疗法4mg/d,持续3个月,然后在接下来的3个月中给予这些患者阿伐他汀10mg/d作为联合疗法。在研究开始时,罗格列酮单一疗法之后以及罗格列酮与阿伐他汀联合治疗之后测量炎性生物标记物,包括高敏C-反应蛋白(hs-CRP)、基质金属蛋白酶9(MMP…     

Human embryo implantation following in-vitro fertilization: is there a seasonal variation?

The purpose of this study was to determine whether there isa seasonal variation in implantation and pregnancy rates followingnatural cycle replacement of cryopreserved embryos. A totalof 321 consecutive cycles were analysed. There were 59 pregnancies(18.4%) and 48 live births or ongoing pregnancies (15.0%). Indicatorvariables for each month and variables representing temporalcycles of 12, 6, 4, 3 and 2 months were related to outcome.In addition, an analysis of periodicity was performed. No temporal,clinical or demographic variable was significantly related topregnancy. This study indicated that there was no clear seasonalvariation in the pregnancy rate following natural cycle replacement.However, the power of this study was low, and it was estimatedthat 963 subjects would be required to detect a 10% seasonaldifference in pregnancy rates.     

Clinico-pathological correlates in IgA nephropathy

Summary: There were 2758 biopsies of glomerulonephritis diagnosed in the Department of Pathology in the 20 years from 1976 to 1995. Of these 1893 (76.1%) were of primary glomerulonephritis while 577 (23.2%) were of secondary glomerulonephritis. Immunofluorescence studies were available in 1494 (80%) cases. Predominantly mesangial IgA staining was seen in 49.1% of cases, thus identifying them as IgA nephropathy. Mesangial glomerulonephritis was found in 79.1% of cases whilst 17.7% had sclerotic lesions either focal or global. One hundred and fifty-one patients were followed up. Of these, 98 (65%) were detected through health screening while 53 (35%) presented with symptoms. Uncontrolled hypertension, proteinuria of more than 2 g, the presence of crescents and glomerulosclerosis on biopsy were unfavourable prognostic factors. Hypertensive patients also had a higher incidence of medial hyperplasia of the blood vessels. However IgA nephropathy is a benign disease with a cumulative renal survival of 91% after 6 years.     

The effect of ethanol on phospholipid metabolism in rat pancreas

The phospholipid effect involves agonist-induced breakdown of phosphatidyl inositol (or polyinositides) generating second messengers followed by increased incorporation of 32P during the resynthetic phase of the cycle. Ethanol, an aetiological factor in pancreatitis, has been shown to have various effects on pancreatic secretion. In this study ethanol decreased the incorporation of 32P into phosphatidyl inositol but had no effect on the stimulated breakdown of prelabelled phosphatidyl inositol. However, in addition to recycling of phosphatidyl inositol stimulation of pancreatic tissue results in increased incorporation of precursors into other phospholipids. Cholecystokinin increased the incorporation of both [U-14C] glucose and 32P into phosphatidyl ethanolamine 3-fold but had no effect on 32P incorporation into phosphatidyl choline. As well as increased incorporation of 32P into phosphatidyl inositol (8-fold) cholecystokinin also increased the incorporation of [U-14C] glucose into phosphatidyl inositol (4-5-fold) implying significant de novo synthesis of 1,2 diacyl glycerol in addition to the currently accepted recycling of the 1,2 diacyl glycerol back to phosphatidyl inositol. Ethanol caused an inhibition of 32P incorporation into total phospholipid of rat pancreas during basal and stimulated conditions. When individual phospholipids were separated ethanol was found to decrease the incorporation of 32P into phosphatidyl choline under basal conditions and into all phospholipids during cholecystokinin stimulation. With [U-14C] glucose as the precursor, ethanol inhibited its incorporation into phosphatidyl choline only. Ethanol did not alter the total 32P radioactivity in the aqueous phase of the pancreatic extract nor the percent incorporated into nucleotides. This excluded decreased uptake of 32P and incorporation into nucleotides as a mechanism for the differential inhibition of 32P versus [U-14C] glucose incorporation into phospholipids other than phosphatidyl choline under stimulated conditions.     

Antenatal detection of small-for-gestational-age babies. Choice of a symphysis-fundus growth curve

By using symphysis-fundus measurements serially and plotting them on a curve, small-for-gestational-age babies can be detected. To determine which symphysis-fundus curve to choose for our population, the predictive values of three of the commonly used of these growth curves were compared using serial measurements obtained from 97 low-risk obstetric patients with accurate gestational ages. The curves of Calvert and Quaranta had the best sensitivities of 92.9% each compared with Belizan's (85.7%). However, the specificity of Calvert's and Quaranta's curves were poorer being 74.7% and 50.6% compared with 89.2% for Belizan. The positive predictive value for the curves were Belizan 57.1%, Calvert 38.2% and Quaranta 24.1%. The results indicate that for a Third-World urban population Belizan's curve is most suitable.     

Early detection of poor fetal prognosis by serial Doppler velocimetry in high-risk pregnancies.

Fifty-three high-risk pregnancies were followed up serially with Doppler velocimetry of the umbilical artery and uterine vessels from early on to investigate whether abnormalities in Doppler waveforms can predict the outcome of pregnancy accurately before other clinical signs develop. Results of Doppler velocimetry were withheld from the clinicians managing the patients. When the absence of end-diastolic velocities was first detected (in 13 fetuses) (AEDV group) there was no clinical difference between these pregnancies and those in which end-diastolic velocities were present (EDV group). Nine of the 13 fetuses with AEDVs died, compared with 3 of 40 with EDVs (P less than 0.0001). In deaths associated with AEDVs, the latter were detected a median of 5.5 (range 3-11) weeks before death and are present from the first Doppler examination. In the 4 fetuses with AEDVs that survived, the AEDVs were not persistent. The only significant association of Doppler velocimetry of the uterine vessels was with proteinuric hypertension (P less than 0.05), but the prediction was not strong enough to be of clinical value. Persistent AEDVs of the umbilical artery are an accurate predictor of poor fetal outcome and occur before other clinical signs of impending problems.