Recurrence of hypertensive disorders of pregnancy: results from a nationwide prospective cohort study (CONCEPTION).

OBJECTIVE: To assess the risk of gestational hypertension (GH) and pre-eclampsia (PE) during a second pregnancy after occurrence during a first pregnancy. DESIGN: Prospective cohort study. SETTING: CONCEPTION is a French nationwide cohort study that used data from the National Health Data System (SNDS) database. METHODS: We included all women who gave birth for the first time in France in 2010-2018 and who subsequently gave birth. We identified GH and PE through hospital diagnoses and the dispensing of anti-hypertensive drugs. The incidence rate ratios (IRR) of all hypertensive disorder of pregnancy (HDP) during the second pregnancy were estimated using Poisson models adjusted for confounding. MAIN OUTCOME MEASURES: Incidence rate ratios of HDP during the second pregnancy. RESULTS: Of the 2 829 274 women included, 238 506 (8.4%) were diagnosed with HDP during their first pregnancy. In women with GH during their first pregnancy, 11.3% (IRR 4.5, 95% confidence interval [CI] 4.4-4.7) and 3.4% (IRR 5.0, 95% CI 4.8-5.3) developed GH and PE during their second pregnancy, respectively. In women with PE during their first pregnancy, 7.4% (IRR 2.6, 95% CI 2.5-2.7) and 14.7% (IRR 14.3, 95% CI 13.6-15.0) developed GH and PE during their second pregnancy, respectively. The more severe and earlier the PE during the first pregnancy, the stronger the likelihood of having PE during the second pregnancy. Maternal age, social deprivation, obesity, diabetes and chronic hypertension were all associated with PE recurrence. CONCLUSION: These results can guide policymaking that focuses on improving counselling for women who wish to become pregnant more than once, by identifying those who would benefit more from tailored management of modifiable risk factors, and heightened surveillance during post-first pregnancies.

The value of combined radionuclide and magnetic resonance imaging in the diagnosis and conservative management of minimal or localized osteomyelitis of the foot in diabetic patients.

Early diagnosis of osteomyelitis is helpful for a successful conservative treatment. The value of bone scanning combined with granulocytes labeled with hexamethylpropylene amine oxime (HMPAO) granulocyte-Tc99m (GN) radionuclide imaging (combined [RI]) with magnetic resonance imaging (MRI) for the diagnosis of osteomyelitis was assessed in 24 diabetic patients with foot ulcers. Evidence of osteomyelitis was based on the presence of at least one of the following criteria: (1) clinical bone involvement, (2) radiological bone involvement, (3) both positive combined RI and MRI, and (4) evidence of clinical bone involvement during the follow-up period. Thirteen patients had osteomyelitis. Seven patients had clinical bone involvement (sensitivity, 54%), five had radiological bone involvement (sensitivity, 38%), and 10 had positive combined RI for osteomyelitis (sensitivity, 77%). MRI demonstrated a higher sensitivity (100%). The specificity for combined RI and MRI was 82%. These results lead to a new diagnostic strategy for the early detection of minimal or localized osteomyelitis to avoid amputations. MRI is most appropriate following a negative x-ray in determining whether to treat osteomyelitis, since a negative MRI result rules out osteomyelitis. Antibiotic therapy should be used in the case of a positive MRI result, but Charcot joint disease can lead to false-positive MRI results. In this case, combined RI should be performed.

National Asthma Education and Prevention Program working group report on the financing of asthma care.

The financing of asthma care is the third topic of the National Asthma Education and Prevention Program Task Force Report on the Cost Effectiveness, Quality of Care, and Financing of Asthma Care. This working group explored the effects of financing on access to services, treatment of asthma, and potential health outcomes. Over the course of a year, the working group collected and analyzed information pertaining to the various types of public and private health care financing mechanisms, including both insurance-based and non-insurance-based issues. The group examined the published literature and gathered information from four public hearings conducted across the nation. The result of this synthesis of information on health care financing and asthma care is a set of 12 recommendations that seek to improve the financing of asthma care.

Cost savings and clinical improvement through disease management.

Cystic fibrosis is an expensive chronic illness that has not historically demonstrated cost savings and quality of care improvement potential by alternate care plans using comprehensive disease management treatment modalities. This case study describes care provided over a 45-month period to an adolescent female with severe cystic fibrosis involving multiple hospitalizations and $396,000 in total cost of care. Treatment plans before and after the initiation of a comprehensive home care disease management program are described. Clinical improvement outcomes and savings of 33.4% in total costs were documented using longitudinal analysis of paid claims data and medical chart review. Guidelines are suggested for case managers desiring to initiate similar programs of care.

[Mycobacterium kansasii infection in patients with human immunodeficiency virus infection]. / Infection à Mycobacterium kansasii chez des patients infectés par le virus de l'immunodéficience humaine.

We report a retrospective study of 12 caucasian men infected with HIV who had developed Mycobacterium kansasii infection (Mk). All patients had a low blood lymphocyte CD4 count (1-130, mean 15/mm3) and ten met the diagnostic criteria for AIDS. The 12 patients had pulmonary symptoms (dyspnea, cough) and fever. On chest X-ray, nodular, interstitial or diffuse parenchymal infiltrates, mediastinal and hilar adenopathies were observed. Two patients had pleural effusion, but none had cavitary lung disease. Mk was isolated by culture of sputum (n = 7), blood (n = 3), bronchial biopsy (n = 2) or bone marrow (n = 1). No patient had clinical extra-pulmonary disease. Survival after diagnosis was in average 7 months. Potential for therapeutic response is reviewed and documented.

[The value of computed tomography in the diagnosis of the local and lymph node recurrences of head and neck tumors]. / Wertigkeit der Computertomographie bei der Diagnose von Lokal- und Lymphknotenrezidiven von Kopf-Hals-Tumoren.

544 CT studies of 231 patients were evaluated retrospectively to assess the role of CT in posttherapeutic monitoring of patients with head and neck tumours. CT (80%) was inferior to clinical evaluation (87%) in diagnosing recurrent malignancy due to a lack of specificity (76 vs. 92%). With CT small recurrencies were missed. Occasionally evaluation of the oral cavity was impaired by metal artifacts (dental fillings). However with larger recurrent tumours, CT offered important additional information regarding extent, infiltration of deeper compartments and bony destruction in 51% of the cases. CT (95%) was superior to clinical evaluation (80%) in diagnosing recurrent lymph node metastases. A baseline CT study at about 6-8 weeks after the end of therapy is of great importance for follow-up studies.

Reinvestigation of the binding of proflavine to DNA. Is intercalation the dominant binding effect?

The binding isotherms of the acridine dye proflavine (PF) to calf-thymus DNA have been carefully redetermined at pH = 6.5 and 25 degrees C. Bound monomers (M), dimers and trimers (D,T) as well as higher polymeric PF cations (P) could be distinguished by absorption spectroscopy. The concentrations of these species were determined as a function of the concentration CMf of free PF cations in solution. NaCl is a competitor (S) for the bound dye cations. The competitive salt effect has been carefully studied in the wide concentration range 0 less than or equal to Cs less than or equal to 1 M. - At very low dye concentrations CMf monomeric and dimeric PF cations M and D are bound to DNA. The binding constant KM of the monomers M depends strongly on the concentration Cs of the competitor and decreases with increasing Cs to a limiting value greater zero. We have developed an extended equilibrium model for the quantitative description of this competitive salt effect. We assume that two types 1 and 2 of the bound monomers exist already at very low CMf and that they can be distinguished by the competitive salt effect: The intercalated monomers 1 are resistant to competitors whereas the pre-intercalatively bound monomers 2 are displaced by Na+ cations. The binding constants of 1 and 2 have been determined by the use of the equilibrium model: KM1 = 3.5 x 10(4) M-1, KM2* = 2.7 x 10(6) M-1. Thus, the binding constant KM1 of the intercalation 1 is very much smaller than the binding constant KM2* of the pre-intercalative bond 2. This is in contradiction to the generally accepted notion that intercalation should be the dominant binding effect. The concentration of bound monomers decreases rapidly with increasing CMf. Instead, DNA-bound dimers D and subsequently trimers T are observed. Both species are very sensitive to competitor cations. We have determined the dependence of the concentrations of bound D and T on the competitor concentration Cs using the extended equilibrium model. The respective binding constants are KD* = 8.7 x 10(4) M-1 and KT* = 2.4 x 10(4) M-1. Finally D and T disappear with increasing CMf. At higher dye concentrations, higher dye polymers P are observed instead of D and T. In contrast to D and T, the binding of P is favoured by cooperative effects.(ABSTRACT TRUNCATED AT 400 WORDS)

Lessons for providers from a purchaser's perspective.

On Jan. 1, 1991, the John Hancock National Transplant Program (JHNTP) became operational, matching kidney, heart, liver, and bone marrow transplant patients from a potential pool comprising more than two million covered lives, with organ transplant programs at 14 institutions across the country. Conceptualizing the program and selecting and contracting with the transplant centers took more than 18 months. This article shares some of the insights from that process that are pertinent to providers of transplant services and to others considering entering this or other forms of specialized contracting.

A new tier of health care management initiatives.

Some employers spend half their health benefits dollars on outpatient care. Utilization of ambulatory services is up, costs-per-case are escalating fast--with some procedures demonstrably costing 85%-95% of inpatient charges--and providers' profits are increasing. Executives of the Health Data Institute and The Associated Group describe a multi-pronged approached to managing the burgeoning costs of a health care delivery alternative that was supposed to save employers money.