Improving Pregnancy Outcomes through Maternity Care Coordination: A Systematic Review.

BACKGROUND: Care during pregnancy is multifaceted and often goes beyond traditional prenatal care from an obstetrical care provider. Coordinating care between multiple providers can be challenging, but is beneficial for providers and patients. Care coordination is associated with decreased costs, greater patient satisfaction, and a reduction in medical errors. To our knowledge, no previous review has examined maternity care coordination (MCC) programs and their association with pregnancy outcomes. METHODS: Using a search algorithm comprised of relevant MCC terminology, studies were identified through a systematic search of PubMed, Scopus, ClinicalTrials.gov, and Google Scholar. Studies meeting eligibility criteria (e.g., defining the care coordination components and examining at least one quantitative outcome) were fully abstracted and quality rated using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. MAIN FINDINGS: Thirty-three observational studies of MCC were included in this review. Quality scores ranged from 27% to 100%. Most studies included strategies with a team approach to decision making and/or individual case management. Social service referrals to outside organizations were also common. Twenty-seven studies reported infant birth weight as a main outcome; 12 found a significant improvement in birth weights among care coordination participants. CONCLUSIONS: Roughly one-third of the included studies reported improved birth weights among care coordination participants. However, it remains unknown what effect care coordination strategies have on patient and provider satisfaction in the prenatal care setting, two aspects of maternity care that may advance the quality and utilization of prenatal health services.

Phone-delivered mindfulness training for patients with implantable cardioverter defibrillators: results of a pilot randomized controlled trial.

BACKGROUND: The reduction in adrenergic activity and anxiety associated with meditation may be beneficial for patients with implantable cardioverter defibrillators. PURPOSE: This study aims to determine the feasibility of a phone-delivered mindfulness intervention in patients with defibrillators and to obtain preliminary indications of efficacy on mindfulness and anxiety. METHODS: Clinically stable outpatients were randomized to a mindfulness intervention (eight weekly individual phone sessions) or to a scripted follow-up phone call. We used the Hospital Anxiety and Depression Scale and the Five Facets of Mindfulness to measure anxiety and mindfulness, and multivariate linear regression to estimate the intervention effect on pre-post-intervention changes in these variables. RESULTS: We enrolled 45 patients (23 mindfulness and 22 control; age, 43-83; 30 % women). Retention was 93 %; attendance was 94 %. Mindfulness (beta = 3.31; p = 0.04) and anxiety (beta = -1.15; p = 0.059) improved in the mindfulness group. CONCLUSIONS: Mindfulness training can be effectively phone-delivered and may improve mindfulness and anxiety in cardiac defibrillator outpatients.

Impact of dose, frequency of administration, and equol production on efficacy of isoflavones for menopausal hot flashes: a pilot randomized trial.

OBJECTIVE: The relatively modest benefit of vasomotor symptom relief in clinical trials of isoflavones may reflect once-daily dosing and low percentages of participants who are able to metabolize daidzein into equol, a potentially more biologically active isoflavone. This pilot study examined whether symptom reduction was greater with more frequent administration and with higher daily doses. In addition, we explored possible effect modification by equol producer status. METHODS: We randomized 130 perimenopausal (no menses in the past 3 mo) and postmenopausal (≥12 mo of amenorrhea) women with a mean of five or more moderate/severe hot flashes per day to treatment arms with varying total daily isoflavone doses and dosing frequency, separately for equol producers and nonproducers. Participants recorded the daily frequency and severity of hot flashes. Analyses compared mean daily hot flash intensity scores (sum of hot flashes weighted by severity) by total daily dose and by dosing frequency. Dose- and frequency-related differences were also compared for equol producers and nonproducers. RESULTS: Hot flash intensity scores were lowest in women randomized to the highest total daily dose (100-200 mg) and in women randomized to the highest dosing frequency (twice daily to thrice daily), with greater benefits on nighttime scores than on daytime scores. Dose- and frequency-related differences were somewhat larger in equol producers than in nonproducers. CONCLUSIONS: These results suggest that a twice-daily to thrice-daily dosing frequency may improve the benefit of isoflavones for vasomotor symptom relief, particularly in equol producers and for nighttime symptoms. Larger studies are needed to confirm these findings.

Phytoestrogen and fiber intakes in relation to incident vasomotor symptoms: results from the Study of Women's Health Across the Nation.

OBJECTIVE: Although reduction of vasomotor symptoms (VMS; hot flashes and night sweats) has been reported in postmenopausal women who used isoflavones, a clear dose response has not been shown, has largely not been reported for perimenopausal women, and has largely only been reported for reducing prevalent VMS, not preventing newly developing VMS. We analyzed longitudinal data from the Study of Women's Health Across the Nation for the relation of dietary phytoestrogen and fiber intake to incident VMS in this multiracial/ethnic cohort. METHODS: The Study of Women's Health Across the Nation included 3,302 premenopausal and early perimenopausal women, 1,651 of whom reported no VMS at baseline and were followed with annual visits for 10 years. Dietary intakes of isoflavones, coumestrol, lignans, and fiber were assessed by a food frequency questionnaire at baseline and in annual visits 5 and 9 and interpolated for intervening years. The number of days experiencing VMS in the past 2 weeks was self-reported annually. Using multinomial logistic regression with generalized estimating equations, we modeled incident VMS in relation to isoflavones, lignans, fiber, coumestrol, or total phytoestrogen intake and covariates. RESULTS: No consistent monotonic relations were observed between any dietary phytoestrogen or fiber and incident VMS, although adjusted odds ratios for some individual quartiles were statistically significant. CONCLUSIONS: For certainty of any effect of dietary phytoestrogens or fiber on the prevention of incident VMS, a randomized, placebo-controlled, double-masked trial with sufficient numbers of women in different racial/ethnic, menopausal status, and metabolic groups over years of follow-up is required, but our results suggest that a clinically significant or large effect is improbable.

Relationship between dietary phytoestrogens and development of urinary incontinence in midlife women.

OBJECTIVE: Because exogenous estrogen treatment has been associated with a higher risk of urinary incontinence, our objective was to evaluate the longitudinal relationships of dietary phytoestrogen intakes (isoflavones, coumestans, and lignans) and the development of incontinence in midlife women transitioning through menopause. METHODS: The Study of Women's Health Across the Nation (SWAN) Phytoestrogen Study was developed within SWAN, a community-based, multisite, multiracial/ethnic, prospective cohort study. SWAN interviewers administered a food consumption assessment at baseline and on follow-up visits 5 and 9. The SWAN Phytoestrogen Study created a phytonutrient database that allowed estimation of the usual daily intakes of four isoflavones, four lignans, and coumestrol. On an annual self-administered questionnaire, participants reported on the frequency and type of incontinence. We used discrete proportional hazards models to evaluate whether the estimated daily intake of each phytoestrogen class on the visit previous to the first report of incontinence was associated with the development of monthly or more incontinence versus remaining continent. RESULTS: We found no association or patterns of association between developing any, stress, or urge incontinence and the reported daily dietary intake of isoflavones, coumestrol, and lignans on the visit previous to the onset of incontinence. CONCLUSIONS: The results of this longitudinal study provide important information to better understand estrogenlike substances in the continence mechanism of midlife women. Our study shows that neither high nor low dietary intakes of isoflavones, coumestrol, and lignans prevent stress or urge incontinence. Future studies should evaluate whether serum levels of phytoestrogens or their metabolites impact incontinence symptoms.

Dietary phytoestrogen intakes and cognitive function during the menopausal transition: results from the Study of Women's Health Across the Nation Phytoestrogen Study.

OBJECTIVE: Phytoestrogens, which consist mainly of isoflavones, lignans, and coumestans have estrogenic and anti-inflammatory properties. Previous research suggests that higher dietary or supplemental intakes of isoflavones and lignans are related to better cognitive performance in middle-aged and older women. METHODS: We conducted longitudinal analysis of dietary phytoestrogens and cognitive performance in a cohort of African American, white, Chinese, and Japanese women undergoing the menopausal transition. The tests were Symbol Digit Modalities, East Boston Memory, and Digits Span Backward. Phytoestrogens were assessed using the Food Frequency Questionnaire. We modeled each cognitive score as a function of concurrent value of the primary predictors (highest tertile of isoflavones, lignans, or coumestrol) and covariates including the menopausal transition stage. RESULTS: Coumestrol and isoflavone intakes were 10 and 25 times greater, respectively, in Asian than in non-Asian participants. During late perimenopause and postmenopause, Asian women with high isoflavone intakes did better on processing speed, but during early perimenopause and postmenopause, high-isoflavone Asian consumers performed worse on verbal memory. The highest isoflavone consumers among non-Asians likewise posted lower verbal memory scores during early perimenopause. A verbal memory benefit of higher dietary lignan consumption was apparent only during late perimenopause, when women from all ethnic/racial groups who were in the highest tertile of intake demonstrated a small advantage. Coumestrol was unrelated to cognitive performance. CONCLUSIONS: The cognitive effects of dietary phytoestrogens are small, seem to be class-specific, vary by menopause stage and cognitive domain, and differ among ethnic/racial groups (but whether this is related to dose or to host factors cannot be discerned).

A longitudinal investigation of coping strategies and quality of life among younger women with breast cancer.

It is generally assumed that coping strategies impact quality of life (QOL). It is plausible that QOL determines use of coping strategies. This research examines coping strategies over time and the reciprocal relationship between coping strategies and QOL among younger women with breast cancer. Women with breast cancer (N = 267; mean age = 43 years) completed surveys within 6 months of diagnosis and 6 weeks and 6 months later. Surveys included questions on coping strategies, QOL, medical factors, and sociodemographics. Positive cognitive restructuring was the most frequently used strategy. Over time, use of seeking social support, spirituality, and wishful thinking declined, while detachment increased. Prior QOL predicted three subsequent coping strategies (seeking social support, keeping feelings to self, wishful thinking). Coping strategies were minimally related to subsequent QOL. Coping strategies and QOL are dynamic processes. QOL may predict coping strategies equally or more than vice versa.