Prognostic model for chronic hypertension in women with a history of hypertensive pregnancy disorders at term.

INTRODUCTION: The association between hypertensive pregnancy disorders and cardiovascular disease later in life is well described. In this study we aim to develop a prognostic model from patients characteristics known before, early in, during and after pregnancy to identify women at increased risk of cardiovascular disease e.g. chronic hypertension years after pregnancy complicated by hypertension at term. METHODS: We included women with a history of singleton pregnancy complicated by hypertension at term. Women using antihypertensive medication before pregnancy were excluded. We measured hypertension in these women more than 2years postpartum. Different patients characteristics before, early in, during and after pregnancy were considered to develop a prognostic model of chronic hypertension at 2-years. These included amongst others maternal age, blood pressure at pregnancy intake and blood pressure six weeks post-partum. Univariable analyses followed by a multivariable logistic regression analysis was performed to determine which combination of predictors best predicted chronic hypertension. Model performance was assessed by calibration (graphical plot) and discrimination (area under the receiver operating characteristic (AUC)). RESULTS: Of the 305 women in who blood pressure 2.5years after pregnancy was assessed, 105 women (34%) had chronic hypertension. The following patient characteristics were significant associated with chronic hypertension: higher maternal age, lower education, negative family history on hypertensive pregnancy disorders, higher BMI at booking, higher diastolic blood pressure at pregnancy intake, higher systolic blood pressure during pregnancy and higher diastolic blood pressure at six weeks post-partum. These characteristics were included in the prognostic model for chronic hypertension. Model performance was good as indicated by good calibration and good discrimination (AUC; 0.83 (95% CI 0.75 - 0.92). CONCLUSION: Chronic hypertension can be expected from patient characteristics before, early in, during and after pregnancy. These data underline the importance and awareness of detectable risk factors both for increased risk of complicated pregnancy as well as increased risk of cardiovascular disease later in life.

Collapse of an iconic conifer: long-term changes in the demography of Widdringtonia cedarbergensis using repeat photography.

BACKGROUND: Conifer populations appear disproportionately threatened by global change. Most examples are, however, drawn from the northern hemisphere and long-term rates of population decline are not well documented as historical data are often lacking. We use a large and long-term (1931-2013) repeat photography dataset together with environmental data and fire records to account for the decline of the critically endangered Widdringtonia cedarbergensis. Eighty-seven historical and repeat photo-pairs were analysed to establish 20th century changes in W. cedarbergensis demography. A generalized linear mixed-effects model was fitted to determine the relative importance of environmental factors and fire-return interval on mortality for the species. RESULTS: From an initial total of 1313 live trees in historical photographs, 74% had died and only 44 (3.4%) had recruited in the repeat photographs, leaving 387 live individuals. Juveniles (mature adults) had decreased (increased) from 27% (73%) to 8% (92%) over the intervening period. Our model demonstrates that mortality is related to greater fire frequency, higher temperatures, lower elevations, less rocky habitats and aspect (i.e. east-facing slopes had the least mortality). CONCLUSIONS: Our results show that W. cedarbergensis populations have declined significantly over the recorded period, with a pronounced decline in the last 30 years. Individuals that established in open habitats at lower, hotter elevations and experienced a greater fire frequency appear to be more vulnerable to mortality than individuals growing within protected, rocky environments at higher, cooler locations with less frequent fires. Climate models predict increasing temperatures for our study area (and likely increases in wildfires). If these predictions are realised, further declines in the species can be expected. Urgent management interventions, including seedling out-planting in fire-protected high elevation sites, reducing fire frequency in higher elevation populations, and assisted migration, should be considered.

High blood pressure six weeks postpartum after hypertensive pregnancy disorders at term is associated with chronic hypertension.

OBJECTIVES: Hypertension in pregnancy is associated with cardiovascular disease (CVD) later in life. Blood pressure monitoring in women who experienced hypertension in pregnancy after puerperium has been suggested to be important for early detection and prevention of CVD. The aim of this study is to evaluate if hypertension six weeks postpartum is associated with chronic hypertension in women with a history of term hypertensive pregnancy disorders. STUDY DESIGN: Women with a history of term gestational hypertension or preeclampsia were included in a follow up study of the HYPITAT trial. Blood pressures were measured six weeks and 2.5years postpartum according to the study protocol. MAIN OUTCOME MEASURES: Hypertension was defined as a diastolic blood pressure ⩾90mmHg and/or a systolic blood pressure ⩾140mmHg or use of antihypertensive medication. Differences in categorical variables between groups were analyzed by Chi-Square tests. Blood pressure was analyzed using unpaired t-tests and Wilcox ranked tests. RESULTS: Among 187 women who had term hypertensive pregnancy disorders, 75 (40%) had hypertension at six weeks postpartum. Of these 46 (61%) had hypertension 2.5years postpartum. In contrast, of 112 women without hypertension at six weeks postpartum, 36 (32%) had hypertension 2.5years (OR 3.3, 95% CI 1.8-6.2). CONCLUSION: Among 61% of women who had hypertensive pregnancy disorders at term, high blood pressure at six weeks postpartum indicated chronic hypertension. This warrants the importance of identification of hypertension 6weeks postpartum for women's future health.

Comparative analysis of recommendations in local Dutch guidelines on 'Hypertension and pregnancy'.

OBJECTIVE: Hypertensive disorders in pregnancy remain the most prevalent cause of maternal and fetal morbidity and mortality. We hypothesise that incompleteness of local protocols 'Hypertension during pregnancy' might be associated with adverse obstetric outcome. Therefore, we analyzed the contents of the local Dutch protocols. STUDY DESIGN: We analyzed local Dutch protocols on 'Hypertension during pregnancy' using qualitative methods to score the completeness using the national guideline as standard. Indicators were designed using key recommendation from the national Dutch guideline 'Hypertension during pregnancy' (n=83 indicators), 22 of these indicators were classified as crucial indicators. Deficiencies in the local Dutch protocols, differences between the protocols and differences between the protocols of academically affiliated hospitals, teaching non-academic hospitals and non-teaching hospitals were analyzed using ANOVA test. RESULTS: The median total score of the local protocols is 32.5 (max 83, range from 2 to 55). Thirteen indicators were described in less than 10% of the local protocols. We found more indicators lacking in the non-teaching hospitals protocols compared to academically affiliated hospitals and teaching non-academically hospitals protocols. (Six of the crucial indicators were described in less than 50% of the local protocols.) CONCLUSIONS: The data from this review imply incompleteness of the local Dutch protocols. Improvement of the protocols can result in improvement of implementation and subsequent improvement of quality care for pregnant women with hypertension finally resulting in better outcome of mother and child.

Implications of the dielectrical behaviour of human blood for continuous online measurement of haematocrit.

A study was designed to explore the possibility of detecting the haematocrit of blood by means of admittance measurements. The admittance and phase angle of blood kept in a measuring cell were determined at various frequencies between 60 kHz and 24 MHz. A reliable and accurate estimation of haematocrit was obtained in two ways. First, low-frequency admittance, high-frequency admittance and a factor x, which was the conductive percentage of cell content, were used. Secondly, the maximum phase angle was used. Both methods can be applied to obtain continuous on-line information about haematocrit for blood volume control during haemodialysis.

Continuous measurement of blood volume during hemodialysis by an optical method.

A new method is described to noninvasively and continuously measure changes in blood volume (BV) during hemodialysis by means of an optical reflection method with an optical monitor (950 nm) clipped onto the arterial blood line. The amount of reflected light (L) appeared to be linearly proportional to the erythrocyte concentration (r = 0.91). Changes in L correlated well with changes in erythrocyte concentration during hemodialysis (r = 0.94). A study in 10 patients on regular dialysis was done. The BV decrease after 3 hr of treatment was 17.0 +/- 5.2%, and it correlated with the amount of fluid withdrawn by ultrafiltration (mean, 2,519 +/- 589 ml). Five hypotensive episodes were seen that were characterized by a higher rate of BV fall during the preceding 15 min (9.9 +/- 1.9 versus 3.6 +/- 4.3%/hrp; p < 0.05) and by a lower BV value at that moment (78.2 +/- 3.4 versus 84.5 +/- 4.5%; p < 0.025) than in the other five patients at comparable times. It was concluded that this optical method was a means to detect hypovolemia at an early stage and to prevent ultrafiltration induced hypotension.

Extracorporeal membrane oxygenation treatment. One-year outcomes for North Carolina infants.

Initial survival rates for the first 45 North Carolina ECMO neonates in the study group are somewhat better than national figures. Developmental functioning as assessed at one year of age is comparable to that reported in other studies. A congenital diaphragmatic hernia diagnosis was significantly related to poorer outcome. Measures of family functioning approximate those reported for families of non-ECMO neonates treated in intensive care. Support provided by ECMO staff was rated at a notably high level. With nearly three thousand survivors and multiple numbers of ECMO centers now operating in this country, ECMO has made the transition from an experimental treatment to an established procedure for treatment of neonates in pulmonary failure. A few beginning attempts to utilize ECMO with older patients are being made. Neonatologists are now directing efforts toward refining techniques and selection criteria. Further evaluation of longer-term effects of this type of treatment is essential. Effective protocols for follow-up care need to be designed, particularly for those at greatest risk for developmental disability.

Measurement of transcellular fluid shift during haemodialysis. Part 2. In vitro and clinical evaluation.

A method to measure intra- and extracellular conductivity is evaluated. In vitro experiments show that these two variables can be measured separately. The conductivity appears to depend on the concentration and fluid volume of the compartment concerned. In vitro variation of the intracellular volume of blood by dilution and by shrinking and swelling of blood cells is detectable by this method. In vivo too the method seems to detect intra- and extracellular fluid volumes separately. The course of these two variables during different strategies of haemodialysis is determined.

Urine culture in the evaluation of suspected neonatal sepsis.

Clinical records of patients in a neonatal intensive care unit were reviewed to determine the efficacy of obtaining a urine culture in the detection of neonatal sepsis. During a 12-month period, 188 sets of concomitant blood and urine cultures were obtained in infants less than 72 hours of age (early onset group) and 189 sets of cultures in infants over 72 hours of age (late onset group). Blood cultures were positive in nine instances in the early onset group and 11 instances in the late onset group. All but one blood culture in each group was accompanied by a negative urine culture. Urine cultures alone were positive in two instances in the early onset group and 13 instances in the late onset group (P less than 0.05). Symptoms did not differentiate infants with bacteremia from infants with bacteruria. Culture of the urine was shown to be necessary for the detection of a significant number of late onset infections. Urine culture in the early onset age group had a significantly lower yield, and the risk of suprapubic bladder tap in this group may not be justified.