ObjectiveLimited data are available from low‐ and middle‐income countries (LMICs) on the relationship of haemoglobin levels to adverse outcomes at different times during pregnancy. We evaluated the association of haemoglobin levels in nulliparous women at two times in pregnancy with pregnancy outcomes.DesignASPIRIN Trial data were used to study the association between haemoglobin levels measured at 6+0–13+6 weeks and 26+0–30+0 weeks of gestation with fetal and neonatal outcomes.SettingObstetric care facilities in Pakistan, India, Kenya, Zambia, The Democratic Republic of the Congo and Guatemala.PopulationA total of 11 976 pregnant women.MethodsGeneralised linear models were used to obtain adjusted relative risks and 95% CI for adverse outcomes.Main outcome measuresPreterm birth, stillbirth, neonatal death, small for gestational age (SGA) and birthweight <2500 g.ResultsThe mean haemoglobin levels at 6+0–13+6 weeks and at 26–30 weeks of gestation were 116 g/l (SD 17) and 107 g/l (SD 15), respectively. In general, pregnancy outcomes were better with increasing haemoglobin. At 6+0–13+6 weeks of gestation, stillbirth, SGA and birthweight <2500 g, were significantly associated with haemoglobin of 70–89 g/l compared with haemoglobin of 110–129 g/l The relationships of adverse pregnancy outcomes with various haemoglobin levels were more marked at 26–30 weeks of gestation.ConclusionsBoth lower and some higher haemoglobin concentrations are associated with adverse fetal and neonatal outcomes at 6+0–13+6 weeks and at 26–30 weeks of gestation, although the relationship with low haemoglobin levels appears more consistent and generally stronger.Tweetable abstractBoth lower and some higher haemoglobin concentrations were associated with adverse fetal and neonatal outcomes at 6–13 weeks and 26–30 weeks of gestation.

Hypertension is one of the most common medical conditions complicating pregnancy, with significant implications on maternal and perinatal morbidity and mortality. Abnormalities in placentation have been implicated as the primary pathology responsible for the development of hypertension during pregnancy and its effects such as pre-eclampsia and eclampsia. With advancing research, the focus is now gradually shifting towards abnormalities in the maternal vasculature, including endothelial damage/dysfunction and impaired repair as a probable cause for this, with the latter being implicated in the development of cardiovascular disorders in later life in these women. Circulating endothelial cells (CECs) are a novel means of assessing endothelial dysfunction are mature cells detached from the vascular intimal layer in response to a variety of insults. Endothelial progenitor cells (EPCs) are non-leukocyte cells derived from the bone marrow with proliferative potential that may be important in vascular regeneration. This review article aims to provide an overview of current literature and concepts relating endothelial damage/dysfunction and impaired repair and the hypertensive disorders in pregnancy, with particular focus on CECs and EPCs.

Background: Stroke is a major cause of premature mortality in Britain, but its burden is markedly greater amongst South Asians. Because of the paucity of data in this area, we investigated the magnitude and impact of risk from cardiovascular comorbidities on survival amongst South Asian stroke patients. Methods: We reviewed hospital case records of consecutive first in life time ischaemic stroke patients [self reported ethnicity and International Classification of Disease (ICD) 10th revision, codes 430-438] admitted to an inner city hospital in the UK between 1997 and 2001. In-hospital mortality data and CVD risk factors were analysed. Five-year mortality data was obtained from the National Health Tracing Services. Results: Of 1474 ischaemic stroke patients, 242 (16%) were South Asian of whom, 143 (59.1%) were male. The prevalence of hypertension was 70.2%, followed by diabetes 56.2%, hyperlipidaemia 7% and myocardial infarction 10.3%. At 5 years follow-up, 40.5% had died. Cumulative event-free survival at 5 years was significantly poorer in patients with diabetes (log-rank test, p = 0.009). On Cox regression analysis, incorporating age, gender and other CVD risk factors, diabetes mellitus was an independent predictor of mortality odds ratio = 1.65 (1.02-2.6, p = 0.039). Hypertension and dyslipidaemia did not discriminate survival amongst South Asian patients. Conclusion: Stroke mortality in South Asians is associated with presence of diabetes mellitus. This highlights the significance of early and intensive CVD risk modification strategies in ethnic minorities particularly in patients with diabetes. Further research is warranted in South Asians to examine the underlying basis and related pathophysiological abnormalities.

A high prevalence of newly detected diabetes mellitus (DM) and impaired glucose tolerance (IGT) has been reported in patients with acute myocardial infarction (AMI) and no previous diagnosis of DM. However, the prevalence of newly detected DM is grossly underestimated by using fasting plasma glucose (FPG). We determined the prevalence of DM and IGT in patients post-AMI from our local mixed ethnicity population, and evaluated the usefulness of oral glucose tolerance testing in such patients. All non-diabetic subjects admitted with AMI underwent a standardised oral glucose tolerance test (OGTT) with 75 g glucose load predischarge in our institution. Fasting and 2-h postchallenge plasma glucose levels were recorded, in addition to admission plasma glucose, serum cholesterol, triglycerides, HDL cholesterol and haemoglobin A1(C)levels. We studied 61 patients [38 (62%) male; mean (SD) age, 64 (12.5) years], of whom 70% were white European and 30% South Asians. Mean (SD) plasma glucose concentration on admission was 6.9 (1.7; range, 5.8-8.1) mmol/l. Newly diagnosed DM and IGT were detected in 31% (95% CI 10-52) and 33% (95% CI 12-53) of patients respectively. Of those with newly detected diabetes only 32% (95% CI 0-69) had FPG > 6.1 mmol/l. The 12 month major adverse cardiac event rate was 4.5%, 15% and 32% in those with normal glucose tolerance, IGT and DM respectively. Previously undiagnosed DM and IGT in patients with AMI is common. The false reassurance of a normal FPG denies a significant proportion of undiagnosed diabetics the chance of early treatment. The importance of OGTT in the diagnostic work up of this vulnerable high-risk group cannot be over-emphasised.

In December 2005, a Working Party for the Joint British Societies (JBS-2) published guidelines on the prevention of cardiovascular disease in clinical practice ‘ to promote a consistent multi-disciplinary approach to the management of people with established atherosclerotic cardiovascular disease and those at high risk of developing symptomatic atherosclerotic disease ’.1 The Working Party has produced a comprehensive document that addresses most aspects of cardiovascular risk prevention. However important issues arise from the JBS-2 guidance in relation to: (i) screening for new diabetes and (ii) the investigation of impaired glucose tolerance. In the section on risk factor assessment, JBS-2 recommends: ‘ if non-fasting glucose is ⩾6.1 mmol/l then measure fasting glucose for evidence of impaired glucose regulation or new diabetes. If this fasting glucose measurement is normal (⩽6.0 mmol/l) there is no need to repeat it ’. JBS-2 is proposing that a single normal fasting glucose measurement is an adequate screening test for new diabetes. There is however a large body of evidence to refute the wisdom of this pragmatic approach, particularly in the ‘at risk’ population in question.2–8 ### Fasting glucose is a poor indicator of impaired glucose regulation The DECODE study group (Diabetes Epidemiology: Collaborative analysis of Diagnostic criteria in Europe) reported a normal fasting blood glucose (FBG) in 31% of subjects confirmed as diabetic on oral glucose tolerance testing (OGTT).2 Evidence from the Euro Heart Survey emphasizes that without the use of OGTT, almost two-thirds of patients with impaired glucose regulation (new detected diabetes or impaired glucose tolerance, IGT) would remain undiagnosed.3 This holds true for both acute and …

The objective of the study was to assess the relative contributions and benefits of chest radiogram and electrocardiogram in detecting left ventricular hypertrophy among adult hypertensives. Seventy consecutive, newly diagnosed hypertensive patients with forty age and sex comparable healthy controls were recruited for the study at the University of Maiduguri Teaching Hospital, Northeast, Nigeria. The echocardiographic mean Left Ventricular Mass (LVM) was 260.8 ± 72.9 g (range 109.8 to 429.8 g) and 136.9 ± 18.1 g (range 104 to 188.9 g) in patients and controls respectively (p<0.001). Echocardiographic LVM correlated fairly with Cardiothoracic Ratio (CTR) on chest X-ray (r = 0.43, p<0.01) followed by SV 2 + RV6 with a correlation of 0.39 (p<0.01). However, in terms of sensitivity, specificity and accuracy in comparison with ECHO LVM, SV2 + RV6 had …

Background— Control of blood pressure (BP) remains suboptimal worldwide. The objective of this study was to determine whether (primary) general practitioners’ (GPs) approach to high BP is in accordance with international guidelines. Methods and Results— We conducted a cross-sectional survey of 1000 randomly selected GPs from urban areas in Pakistan during 2002. A rigorously developed questionnaire on (1) type of practice and (2) detection, (3) evaluation, (4) treatment, and (5) source of information about high BP was administered by trained medical personnel. A total of 1051 GPs were approached, and 1000 (95%) consented to enroll; 766 were male and 655 had been in practice ≥10 years. The average number of patients (SD) seen per day was 48.2 (42.7). Overall, 30.6% (29.0% to 32.3%) and 79.7% (78.3% to 81.0%) of GPs used incorrect BP cutoffs to diagnose hypertension in patients <60 and ≥60 years, respectively. Appropriate therapy for hypertension in the elderly was initiated by only 34.7% (33.0% to 36.3%) of GPs. The use of sedatives either alone (23.8%) or in combination with antihypertensive agents as first-line medication for lowering BP was reported by 45.0% (43.2% to 46.7%). Thiazide diuretics were rarely prescribed (4.2%). Sublingual antihypertensive agents were prescribed by 68.7% (67.1% to 70.3%) of GPs for treating very high levels of BP. The practices of recent graduates from medical school were not better than those of older graduates. Conclusions— GPs in Pakistan underdiagnose and undertreat high BP, especially in the elderly. Our findings underscore the need for urgent revision of teaching curricula in medical schools with regard to the risks, complications, and management of hypertension, as well as the initiation of widespread and intensive continuing medical education for all physicians involved in the management of patients with hypertension. Particular efforts are needed to encourage the use of low-cost thiazide diuretics as antihypertensive agents in developing countries.

Objective We conducted this study to determine the prevalence of coronary artery disease (CAD) and its risk factors in Karachi, Pakistan.Background Migrant South. Asians residing in the West have one of the highest rates of CAD in the world. Estimates of disease in nonmigrant populations are conflicting.Methods We conducted a population-based cross-sectional survey on 320 randomly selected adults aged >= 40 years. Coronary artery disease was defined as the composite outcome of (1) abnormalities indicative of definite or probable CAD based on the Minnesota classification of electrocardiogram or (2) past history of heart attack.Results The overall prevalence of CAD (95% CI) was 26.9% (22.3%-32.0%): 23.7% (17.8%-30.9%) in men vs 30.0% (23.4-37.5%) in women (P = .12). Risks did not differ substantially by age group. The factors (odds ratio, 95% Cl) independently associated with CAD were current tobacco use (2.12, 1.21-3.73), systolic blood pressure (1.08, 1.02-1.15, for each 5 mm Hg increase), and proteinuria (2.49, 1.04-5.95). Coronary artery disease. odds for women vs men (1.38, 0.84-2.62) increased to 1.60 (0.93-2.75), when adjusted for key risk factors.Conclusions One in 4 middle-aged adults in Pakistan has prevalent CAD. Risks are uniformly high in the young and in women. Concerted efforts are needed to prevent the epidemic of cardiovascular disease in South Asia, focusing on hypertension, diabetes, smoking, and dyslipidemia.

Aims To study the within ethnic subgroup variations in diabetes and central obesity among South Asians.Methods Data from 9442 individuals age greater than or equal to 15 years from the National Health Survey of Pakistan (NHSP) (1990-1994) were analysed. Diabetes was defined as non-fasting blood glucose greater than or equal to 7.8 mmol/l, or known history of diabetes. Central obesity was measured at the waist circumference. Distinct ethnic subgroups Muhajir, Punjabi, Sindhi, Pashtun, and Baluchi were defined by mother tongue.Results The age-standardized prevalence of diabetes varied among ethnic subgroups (P = 0.002), being highest among the Muhajirs (men 5.7%, women 7.9%), then Punjabis (men 4.6%, women 7.2%), Sindhis (men 5.1%, women 4.8%), Pashtuns (men 3.0%, women 3.8%), and lowest among the Baluchis (men 2.9%, women 2.6%). While diabetes was more prevalent in urban vs. rural dwellers [odds ratio (OR) 1.50, 95% confidence interval (CI) 1.24, 1.82], this difference was no longer significant after adjusting for central obesity (OR 1.15, 95% CI 0.95, 1.42). However, the ethnic differences persisted after adjusting for major sociodemographic risk factors (unadjusted OR for Pashtun vs. Punjabi 0.59, 95% CI 0.42, 0.84, adjusted OR 0.54, 95% CI 0.37, 0.78). Ethnic variation was also observed in central obesity, which varied with gender, and did not necessarily track with ethnic differences in diabetes.Conclusions Unmeasured environmental or genetic factors account for ethnic variations in diabetes and central obesity, and deserve further study.