Little is known about the effects of the Chronic Care Model (CCM) and community health workers (CHWs) on pharmacotherapy of type 2 diabetes and hypertension in resource-poor settings. This retrospective cohort implementation study evaluated the effects of a community-based program consisting of CCM, CHWs, guidelines-based treatment protocols, and inexpensive freely accessible medications on type 2 diabetes and hypertension pharmacotherapy quality. A door-to-door household survey identified 856 adults 35 years of age and older living in a low-income Peruvian community, of whom 83% participated in screening for diabetes and hypertension. Patients with confirmed type 2 diabetes and/or hypertension participated in the program's weekly to monthly visits for < = 27 months. The program was implemented as two care periods employed sequentially. During home care, CHWs made weekly home visits and a physician made treatment decisions remotely. During subsequent clinic care, a physician attended patients in a centralized clinic. The study compared the effects of program (pre- versus post-) (N = 262 observations), and home versus clinic care periods (N = 211 observations) on standards of treatment with hypoglycemic and antihypertensive agents, angiotensin converting enzyme inhibitors, and low-dose aspirin. During the program, 80% and 50% achieved hypoglycemic and antihypertensive standards, respectively, compared to 35% and 8% prior to the program, RRs 2.29 (1.72-3.04, p <0.001) and 6.64 (3.17-13.9, p<0.001). Achievement of treatment standards was not improved by clinic compared to home care (RRs 1.0 +/- 0.08). In both care periods, longer retention in care (>50% of allowable time) was associated with achievement of all treatment standards. 85% compared to 56% achieved the hypoglycemic treatment standard with longer and shorter retention, respectively, RR 1.52 (1.13-2.06, p<0.001); 56% compared to 27% achieved the antihypertensive standard, RR 2.11 (1.29-3.45, p<0.001). In a dose-dependent manner, the community-based program was associated with improved guidelines-based pharmacotherapy of type 2 diabetes and hypertension.

OBJECTIVE:We hypothesized that predictive value of traditional Ebola virus disease (EVD) screening in West African pregnant women is low because febrile and hemorrhagic complications of pregnancy that can mimic EVD are common.METHODS:Proportions of various categories of pregnancy loss from a hypothetical cohort of West African gravidas were used to construct a Kaplan-Meier curve. The incidence rate of each category was determined by multiplying its proportion by the overall incidence rate, calculated from the inverse of the area under the curve. Incidence rates of Ebola-like illnesses during pregnancy were obtained by multiplying their percentages by the incidence rates of categories of loss with which they coincide.RESULTS:During pregnancy about 1.5% of suspected EVD cases would prove to have EVD. Most of the remaining 98.5% would have hemorrhagic and febrile complications of pregnancy.CONCLUSION:Current guidelines consider obstetrical interventions inappropriate in suspected EVD during pregnancy. However, because the overwhelming majority of cases suspected by screening do not have EVD and might benefit from obstetrical intervention, policy makers must consider whether the small risk to properly protected health care workers from the 1.5% with true EVD justifies withholding potentially life-saving care from the 98.5% who ultimately test negative for EVD.

We devised a method to predict risk of neonatal Erb palsy using variables ascertainable before delivery. Multiple logistic regression modeling was used to construct an Erb palsy risk score from a case-control study of 45 consecutive Erb palsy cases and 90 controls. Receiver-operator characteristics identified a range of scores for which likelihood ratios were determined for calculation of predictive values across a range of prior probabilities. In the final model, large estimated fetal weight, gestational diabetes, large maternal body mass index, large weight gain, and black race were associated with 2.3-4.8 times greater odds of Erb palsy. A long second stage had a modest effect on the odds (OR=2.7, P=0.13), unless preceded by a long deceleration phase, which combination increased the odds of Erb palsy to 20.1 (P=0.001). A risk score of 0.72 had a sensitivity of 36% and a specificity of 99%. In a theoretical population with a birth prevalence of brachial plexus palsy of 2.5/1000, application of the risk score would prevent 36% of cases and result in about 14 cesareans for every nerve injury prevented. We conclude that risk scoring using multiple logistic regression coefficients of variables that can be known in time to affect decision-making about mode of delivery has the potential to guide intervention to prevent some Erb palsies.

Obstetric Anesthesia Digest: March 2008 - Volume 28 - Issue 1 - p 33-34 doi: 10.1097/01.aoa.0000308316.31188.58

ObjectiveTo determine risk factors for Erb's palsy, with a focus on graphic labour patterns.Design A case-control study.Setting New York City.Sample A total of 45 consecutive cases of Erb's palsy and 90 controls.Methods Pregnancies and labours of neonatal Erb's palsy cases were compared with 90 controls using univariate and multiple logistic regression analysis.Main outcome measures Erb's palsy and shoulder dystocia.Results Mothers of children with Erb's palsy had a higher term body mass index and more gestational diabetes than those of controls. Even cases without diabetes had higher blood glucose values after a 50-g glucose challenge than did controls. Cases had a higher birthweight and a lower ratio of head-to-thoracic circumference than controls. Shoulder dystocia occurred in 67% of cases and in 2% of controls (P = 0.001). Only 46% of labours had a completely normal dilatation pattern. In a multiple logistic regression model, variables independently associated with brachial plexus injury were long deceleration phase of labour, long second stage, high birthweight, black race, and high neonatal or maternal body mass.Conclusions Erb's palsy was frequently preceded by abnormal labour and shoulder dystocia; however, a substantial proportion of cases occurred after normal labour and delivery. Predictive models will be necessary to determine to what extent careful monitoring of the terminal portion of dilatation and of fetal descent and incorporation of maternal body mass and race (all independent risk factors in this study) will help identify fetuses at risk for brachial plexus palsy.

International Journal of Gynecology & ObstetricsVolume 70, Issue S2 p. B72-B72 Preterm labor Influences on maternal corticosteroid therapy prior to preterm birth John E. Deaver, John E. DeaverSearch for more papers by this authorWayne R. Cohen, Wayne R. CohenSearch for more papers by this author John E. Deaver, John E. DeaverSearch for more papers by this authorWayne R. Cohen, Wayne R. CohenSearch for more papers by this author First published: 10 December 2003 https://doi.org/10.1016/S0020-7292(00)85137-1AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume70, IssueS22000Pages B72-B72 RelatedInformation

Objective: The purpose of this study was to assess the effect of several maternal variables on the serologic response following the treatment of syphilis in pregnancy. Methods: A 5-year chart review identified 95 patients coded with syphilis at Hermann Hospital. Inclusion criteria were 1) serologically confirmed syphilis infection during the index pregnancy, 2) complete treatment during the index pregnancy, and 3) minimum of one follow-up rapid plasma reagin (RPR) titer. Forty-nine of 95 patients met the inclusion criteria. Treatment response was evaluated by comparing each post-treatment titer of a patient to her pretreatment titer. Each comparison was considered an “observation.” Each observation was classified as either a positive response (≥4-fold titer decline) or a negative response (<4-fold titer decline). Maternal variables assessed included 1) prior history of syphilis untreated or incompletely treated prior to the index pregnancy, 2) gestational age, 3) titer level, 4) unknown duration, 5) positive response at 1 month, 6) positive response at 2 months, 7) positive response at >3 months, and 8) race. Results: A positive response following treatment was significantly more likely if there was no prior history of syphilis or if there was a high initial RPR titer (>32). Only 33/54 (61%) observations at or greater than 3 months had a positive response. Conclusions: Our study suggests that an absence of a history of syphilis and an initial high RPR titer are predictive of a positive response following appropriate treatment. Given the low percentage of observations with a positive response at 3 months, we speculate that we may be undertreating our pregnant patients with syphilis infection.

We reviewed 58 literature reports of neonatal alloimmune thrombocytopenic purpura (NAITP). The mortality rate was 9%. The total incidence of suspected intracranial hemorrhage was 28%. We reviewed 17 sibship cases for the relation of birth order to treatment and outcome. Among firstborn affected infants (n = 17) the mortality rate and incidence of central nervous system sequelae were 24 and 47%, respectively, compared to rates of 5 and 15%, respectively, in their younger affected siblings (n = 20). The improved outcome in the latter group appeared to be related to more frequent cesarean section delivery and more frequent and earlier use of corticosteroids and maternal platelet transfusions in the neonate. Sensitive assays of maternal platelet alloantibody are now available, but they lack specificity for NAITP affecting the current gestation. There are two reports in which sensitive assays revealed rising titers of maternal platelet alloantibody during advancing gestation. We propose further study to determine if this is specific for the antepartum diagnosis of NAITP.

We report a case of a sibling pair with neonatal alloimmune thrombocytopenic purpura. Serial antepartum platelet alloantibody quantitation by an enzyme-linked immunoabsorbent assay revealed rising antibody titers during advancing gestation. We discuss the implications of this finding in the antepartum diagnosis of neonatal alloimmune thrombocytopenic purpura, a rare, but frequently fatal disorder.