Coronary heart disease (CHD) mortality rates in the United States have declined by up to two thirds in recent decades. Closer examination of these trends reveals substantial inequities in the ...distribution of mortality benefits. It is worrying that the uneven distribution of CHD that exists from lowest to highest social class—the social gradient—has become more pronounced in the United States since 1990 and is most pronounced for women.
Here we consider ways in which this trend disproportionately affects premenopausal women aged 35 to 54 years. We apply a social determinants of health framework focusing on intersecting axes of inequalities—notably gender, class, ethnicity, geographical location, access to wealth, and class—among other power relations to which young and middle-aged women are especially vulnerable, and we argue that increasing inequalities may be driving these unprecedented deteriorations. We conclude by discussing interventions and policies to target and alleviate inequality axes that have potential to promote greater equity in the distribution of CHD mortality and morbidity gains.
The application of this framework in the context of women’s cardiovascular health can help shed light regarding why we are seeing persistently poorer outcomes for premenopausal US women.
This study investigated the prospective relationships between mental health symptoms (depressive and anxiety symptoms) and body mass index (BMI) in women with and without excessive weight gain during ...pregnancy. The secondary aim was to examine whether mental health symptoms and BMI were predictive of one another. Two models were tested: the first depicted depressive or anxiety symptoms predicting BMI, and the second model depicted BMI predicting depressive or anxiety symptoms.
Women completed questionnaires at three time points throughout pregnancy, which comprised of the Depression, Anxiety and Stress Scale-21 and self-reported weight. Height and weight were also reported retrospectively at T1 to calculate pre-pregancy BMI category. To calculate total gestational weight gain (GWG), pre-pregnancy weight was substracted from weight at 36 weeks gestation.
183 women were tracked during pregnancy; Time (T)1 (mean=16.50 weeks of gestation, SD=.92), T2 (mean=24.40 weeks of gestation, SD=.92), and T3 (mean=32.61 weeks gestation, SD=.88). The sample was divided into those for whom weight gain exceeded the guidelines for GWG (excessive gestational weight gain; EGWG), and those who for whom it did not. Multigroup path analyses compared the longitudinal relationships between depressive or anxiety symptoms and BMI during pregnancy for women with and without EGWG.
BMI did not predict depressive or anxiety symptoms. Depressive symptoms at T1, did however predict higher BMI at T2 for women without EGWG. Anxiety symptoms and BMI were not related, regardless of GWG status.
These findings suggest that depressive symptoms may precede increased BMI during pregnancy in women who do not gain weight excessively. There may be longitudinal relationships between depressive symptoms and BMI during pregnancy; however, further research is required to identify the mechanisms that link these health outcomes and inform the focus of intervention design.
Oxygen saturation and outcomes in preterm infants Stenson, Ben J; Tarnow-Mordi, William O; Darlow, Brian A ...
The New England journal of medicine,
05/2013, Letnik:
368, Številka:
22
Journal Article
Recenzirano
Odprti dostop
The clinically appropriate range for oxygen saturation in preterm infants is unknown. Previous studies have shown that infants had reduced rates of retinopathy of prematurity when lower targets of ...oxygen saturation were used.
In three international randomized, controlled trials, we evaluated the effects of targeting an oxygen saturation of 85 to 89%, as compared with a range of 91 to 95%, on disability-free survival at 2 years in infants born before 28 weeks' gestation. Halfway through the trials, the oximeter-calibration algorithm was revised. Recruitment was stopped early when an interim analysis showed an increased rate of death at 36 weeks in the group with a lower oxygen saturation. We analyzed pooled data from patients and now report hospital-discharge outcomes.
A total of 2448 infants were recruited. Among the 1187 infants whose treatment used the revised oximeter-calibration algorithm, the rate of death was significantly higher in the lower-target group than in the higher-target group (23.1% vs. 15.9%; relative risk in the lower-target group, 1.45; 95% confidence interval CI, 1.15 to 1.84; P=0.002). There was heterogeneity for mortality between the original algorithm and the revised algorithm (P=0.006) but not for other outcomes. In all 2448 infants, those in the lower-target group for oxygen saturation had a reduced rate of retinopathy of prematurity (10.6% vs. 13.5%; relative risk, 0.79; 95% CI, 0.63 to 1.00; P=0.045) and an increased rate of necrotizing enterocolitis (10.4% vs. 8.0%; relative risk, 1.31; 95% CI, 1.02 to 1.68; P=0.04). There were no significant between-group differences in rates of other outcomes or adverse events.
Targeting an oxygen saturation below 90% with the use of current oximeters in extremely preterm infants was associated with an increased risk of death. (Funded by the Australian National Health and Medical Research Council and others; BOOST II Current Controlled Trials number, ISRCTN00842661, and Australian New Zealand Clinical Trials Registry numbers, ACTRN12605000055606 and ACTRN12605000253606.).
To compare neonatal mortality associated with six novel vulnerable newborn types in 125.5 million live births across 15 countries, 2000-2020.
Population-based, multi-country study.
National data ...systems in 15 middle- and high-income countries.
We used individual-level data sets identified for the Vulnerable Newborn Measurement Collaboration. We examined the contribution to neonatal mortality of six newborn types combining gestational age (preterm PT versus term T) and size-for-gestational age (small SGA, <10th centile, appropriate AGA, 10th-90th centile or large LGA, >90th centile) according to INTERGROWTH-21st newborn standards. Newborn babies with PT or SGA were defined as small and T + LGA was considered as large. We calculated risk ratios (RRs) and population attributable risks (PAR%) for the six newborn types.
Mortality of six newborn types.
Of 125.5 million live births analysed, risk ratios were highest among PT + SGA (median 67.2, interquartile range IQR 45.6-73.9), PT + AGA (median 34.3, IQR 23.9-37.5) and PT + LGA (median 28.3, IQR 18.4-32.3). At the population level, PT + AGA was the greatest contributor to newborn mortality (median PAR% 53.7, IQR 44.5-54.9). Mortality risk was highest among newborns born before 28 weeks (median RR 279.5, IQR 234.2-388.5) compared with babies born between 37 and 42 completed weeks or with a birthweight less than 1000 g (median RR 282.8, IQR 194.7-342.8) compared with those between 2500 g and 4000 g as a reference group.
Preterm newborn types were the most vulnerable, and associated with the highest mortality, particularly with co-existence of preterm and SGA. As PT + AGA is more prevalent, it is responsible for the greatest burden of neonatal deaths at population level.
Abstract
Objective
We aimed to compare the prevalence and neonatal mortality associated with large for gestational age (LGA) and macrosomia among 115.6 million live births in 15 countries, between ...2000 and 2020.
Design
Population‐based, multi‐country study.
Setting
National healthcare systems.
Population
Liveborn infants.
Methods
We used individual‐level data identified for the Vulnerable Newborn Measurement Collaboration. We calculated the prevalence and relative risk (RR) of neonatal mortality among live births born at term + LGA (>90th centile, and also >95th and >97th centiles when the data were available) versus term + appropriate for gestational age (AGA, 10th–90th centiles) and macrosomic (≥4000, ≥4500 and ≥5000 g, regardless of gestational age) versus 2500–3999 g. INTERGROWTH 21st served as the reference population.
Main outcome measures
Prevalence and neonatal mortality risks.
Results
Large for gestational age was common (median prevalence 18.2%; interquartile range, IQR, 13.5%–22.0%), and overall was associated with a lower neonatal mortality risk compared with AGA (RR 0.83, 95% CI 0.77–0.89). Around one in ten babies were ≥4000 g (median prevalence 9.6% (IQR 6.4%–13.3%), with 1.2% (IQR 0.7%–2.0%) ≥4500 g and with 0.2% (IQR 0.1%–0.2%) ≥5000 g). Overall, macrosomia of ≥4000 g was not associated with increased neonatal mortality risk (RR 0.80, 95% CI 0.69–0.94); however, a higher risk was observed for birthweights of ≥4500 g (RR 1.52, 95% CI 1.10–2.11) and ≥5000 g (RR 4.54, 95% CI 2.58–7.99), compared with birthweights of 2500–3999 g, with the highest risk observed in the first 7 days of life.
Conclusions
In this population, birthweight of ≥4500 g was the most useful marker for early mortality risk in big babies and could be used to guide clinical management decisions.
Increased heart rate and a prolonged QT interval are important risk factors for cardiovascular morbidity and mortality, and can be influenced by the use of various medications, including ...tricyclic/tetracyclic antidepressants (TCAs). We aim to identify genetic loci that modify the association between TCA use and RR and QT intervals.
We conducted race/ethnic-specific genome-wide interaction analyses (with HapMap phase II imputed reference panel imputation) of TCAs and resting RR and QT intervals in cohorts of European (n=45 706; n=1417 TCA users), African (n=10 235; n=296 TCA users) and Hispanic/Latino (n=13 808; n=147 TCA users) ancestry, adjusted for clinical covariates. Among the populations of European ancestry, two genome-wide significant loci were identified for RR interval: rs6737205 in
(β=56.3, p
=3.9e
) and rs9830388 in
(β=25.2, p
=1.7e
). In Hispanic/Latino cohorts, rs2291477 in
significantly modified the association between TCAs and QT intervals (β=9.3, p
=2.55e
). In the meta-analyses of the other ethnicities, these loci either were excluded from the meta-analyses (as part of quality control), or their effects did not reach the level of nominal statistical significance (p
>0.05). No new variants were identified in these ethnicities. No additional loci were identified after inverse-variance-weighted meta-analysis of the three ancestries.
Among Europeans, TCA interactions with variants in
and
were identified in relation to RR intervals. Among Hispanic/Latinos, variants in
modified the relation between TCAs and QT intervals. Future studies are required to confirm our results.
The effect of fluid balance on respiratory outcomes for critically ill children has not been evaluated. The only indicator of fluid balance routinely recorded across our intensive care units was ...estimated fluid intake and output. We sought to determine whether cumulative intake minus output (I-O) at the start of weaning predicted weaning duration and whether cumulative I-O at extubation predicted extubation failure.
Prospective observational study.
Ten pediatric intensive care units.
Cumulative I-O was recorded daily for 301 mechanically ventilated children (<18 yrs of age) from November 1999 through April 2001.
Cumulative I-O was recorded during a study of weaning strategies and extubation failure in which mechanical ventilation of the majority of patients during weaning and extubation was managed according to a protocol that did not include fluid balance indicators. Outcomes were the time to successful removal of ventilatory support and the rate of initial extubation failure.
Relationships between cumulative I-O and outcomes were assessed by means of proportional hazards and logistic regression. The mean cumulative I-O per kilogram of ideal body weight at the start of weaning was 101 mL (sd, 180). Cumulative I-O at the time weaning was initiated did not predict duration of mechanical ventilator weaning. The mean cumulative I-O per kilogram of ideal body weight at extubation was 136 mL (sd, 237). Cumulative I-O at extubation did not predict extubation outcome. There was an association between cumulative I-O at extubation and the duration of weaning in cases not managed by a protocol.
Although routinely recorded, cumulative fluid I-O does not appear to have clinical utility in cases managed according to a mechanical ventilator protocol in which tidal volume and oxygenation on minimal levels of ventilator support are systematically tested.
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