Abstract
The Lancet
Effect of a Participatory Intervention with Women's Groups on Birth Outcomes in Nepal: Cluster-Randomised Controlled Trial
Nepal is a developing country with a high rate of maternal, infant, and neonatal mortality, which is partially due to the lack of health care in most pregnancies. Greater than 90% of women in many rural districts of Nepal deliver at home, with no health care worker present. Deliveries are often unhygienic and follow a pregnancy with no prenatal care. Medical facilities are scarce in rural Nepali districts, and women are not taught to seek out assistance with pregnancy or childbirth. This group developed a community outreach program in a rural area of Nepal to assess its effect on neonatal mortality rates.
The Makwanpur district of Nepal is divided into 43 districts, which were then divided into 21 pairs of study groups, with 1 excluded for security reasons. Groups were paired according to similarities in ethnic diversity and population densities and were then designated as intervention or control group by coin toss. Married women of reproductive age were enrolled in each district and gave verbal consent for study participation. All women in the intervention groups were required to give 1 interview at approximately 7 months of pregnancy and 1 month postpartum and participated in monthly women's groups with a local facilitator. The facilitator was hired and trained in basic perinatal health issues by the investigators, and had no preceding medical training or expertise. All districts, both control and interventions, received basic medical supplies including baby warmers, neonatal resuscitation equipment, and newborn care kits, which included bulb suction syringe, iodine, gauze, and an instruction manual.
Outcomes, including neonatal mortality, maternal health and mortality, stillbirths, infant mortality, home care practices, and health care seeking, were examined in a cohort that included 28 931 women. Eight percent of these women joined the women's groups. The children of women that participated in women's groups had 30% lower neonatal mortality than children of control groups. (26 deaths per 1000 in intervention compared to 37 deaths per 1000 in control groups). Women in intervention groups had significantly lower maternal mortality and were more likely to undergo antenatal care, institutional birth, and to use hygienic birthing practices.
This group from the Mother and Infant Research Activities (MIRA) was able to develop an extremely low-cost method of lowering neonatal and maternal mortality as well as to improve the hygienic practices of many high-risk women. Women were inspired to attend the groups despite no financial incentive and took the time away from other tasks to attend the groups. Expansion of this public health project should be prioritized and should be considered a model for other developing nations.
(Lancet. 2004;364:970–979) DS Manandhar, D Osrin, BP Shrestha, et al Prepared by Karen Nolan Kuehl, MD Oregon Health & Science University, Portland, OR, USA
New England Journal of Medicine
Outcomes of Allergy to Insect Stings in Children, With and Without Venom Immunotherapy
Hymenoptera stings commonly occur in children that participate in long periods of outdoor play. Systemic and local cutaneous reactions can occur in conjunction with stings, but the prevalence of a fatal allergic reaction is low. However, without genuine data to support the hypothesis, it has been long thought that children may “outgrow” an allergy to insect stings. This study involved the long-term follow-up of pediatric patients diagnosed with an allergic reaction to an insect sting between 1978 and 1985.
A telephone and mail survey of past pediatric patients was completed between January 1997 and January 2000 to evaluate outcomes between 1987 and 1999. Telephone survey was used to evaluate most patients, and mail survey was used for those patients who no longer could be contacted by phone. Patients were asked about symptoms, time course of reaction, severity, and treatment. Large local reactions were described as 12 cm in diameter and with resolution within 24 to 48 hours after envenomation. Mild (cutaneous) systemic allergic reactions included urticaria and/or angioedema distant from the sting site. Moderate to severe reactions included cutaneous symptoms but also involved airway complaints, lightheadedness, respiratory distress of varying levels, and mental status changes.
Of 1033 patients, 512 (50%) responded. Respondents included 46% of patients who had received venom immunotherapy and 53% of those who had not. Fifty-four percent of patients had a history of mild (cutaneous) systemic allergic reactions and 44% had moderate-to-severe reactions. The mean time to follow-up between initial diagnosis and the survey was 18 years and the mean time between the initial diagnosis and most recent sting was 13 years. The rate of recurrent stings was similar between those patients undergoing immunotherapy and those without immunotherapy. However, the incidence of systemic reactions during the follow-up period was significantly lower in those who had undergone immunotherapy after the initial diagnosis was made (P = .007). The frequency of patients having a systemic allergic reaction did decline as they aged, but this was not statistically significant.
Study results suggest that children do not necessarily outgrow allergic reactions to hymenoptera stings. In addition, venom immunotherapy given after moderate and severe systemic allergic reactions did prevent systemic reactions in a significant number of children/adults for up to 20 years after treatment had been completed. These data did not show an improvement in outcomes of those with a history of a local or mild cutaneous reaction. This study may cause increased provision of venom immunotherapy in children who suffer from a moderate or severe allergic reaction to an initial bee sting.
(N Engl J Med. 2004;351:668–674) DBK Golden, A Kagey-Sobotka, PS Norman, RG Hamilton, and LM Lichtenstein Prepared by Karen Nolan Kuehl, MD Oregon Health & Science University, Portland, OR, USA
Annals of Internal Medicine
Sildenafil Increased Exercise Capacity During Hypoxia at Low Altitudes and at Mount Everest Base Camp
Acute and chronic hypoxia cause pulmonary hypertension leading to systemic hypoxemia, changes in gas exchange in the lungs, and decreased right ventricular function. All of these physiologic changes can produce decreased exercise tolerance in affected individuals. Sildenafil has been shown to act as a selective pulmonary vasodilator in patients with known pulmonary hypertension from lung disease. The resultant vasodilatation leads to decreased systolic pulmonary arterial pressures (sPAP) and improved gas exchange in treated patients. A group of German physicians theorized that sildenafil could be used at high altitude to reduce pulmonary hypertension resulting from low levels of environmental oxygen and thus improve exercise tolerance.
Fourteen volunteers (8 mountaineers and 6 trekkers) were enrolled in the randomized, double blind, placebo-controlled crossover trial. All subjects were healthy with no history of high-altitude pulmonary edema. Acute hypoxia was induced at sea level in all volunteers by providing a hypoxic gas mixture of 10% fraction of inspired oxygen. Each participant received sildenafil or placebo and underwent testing of systolic pulmonary artery pressure, cardiac output, and peripheral arterial oxygen saturation at rest and during exercise. By crossover design, each participant repeated the low-altitude study on the converse of sildenafil or placebo 24 hours after initial testing. Effects of chronic hypoxia were evaluated after graded ascent to Mount Everest base camp (5245 m). Identical testing was then repeated with each participant taking the sildenafil/placebo crossover. Systolic pulmonary artery pressures were determined by use of a portable Doppler echocardiography device and cardiac output was measured using a gas-rebreather technique.
Results of the study showed sildenafil to have an effect in both acute and chronic hypoxia. At low altitude, hypoxia caused oxygen saturations to drop to 72% at rest and 61% with exercise, and for sPAP to rise from 31 mm Hg at rest to 43 mm Hg with exercise. Once sildenafil was given, the effects of hypoxia were significantly blunted, as evidenced by increased oxygen saturations with exercise (P = .005), decreased sPAP at rest (P < .001), decreased sPAP with exercise (P = .031), increased workload (P < .001), and increased maximum cardiac output (P < .001). At high altitude, sildenafil did not change oxygen saturations at rest or exertion. However, it did decrease sPAP at rest (P = .003) and with exercise (P = .021). Importantly, sildenafil increased maximum workload (P = .02) and increased cardiac output (P = .015) at altitude.
Although the study is small and does not include a baseline control group, the authors’ assertions are correct that sildenafil is the “first drug shown to increase exercise capacity during severe hypoxia at sea level and at high altitude.” Additional studies must be completed to evaluate the true effects of sildenafil on the athletic performance of mountaineers, as well as the ability of sildenafil to prevent high-altitude pulmonary edema.
(Ann Intern Med. 2004;141(3):169–177) HA Ghofrani, F Reichenberger, MG Kohstall, et al. Prepared by Karen Nolan Kuehl, MD Oregon Health & Science University, Portland, OR, USA
Medicine and Science in Sports Medicine
Metabolic and Cardiovascular Parameters in Type I Diabetes at Extreme Altitudes
People with type I diabetes participate in athletics at all levels despite having a multisystem disease. Physical activity is strongly encouraged by the American Diabetes Association (ADA) as it may slow the onset of diabetic complications. Activity at extreme altitude, however, alters normal physiology and metabolism in ways not seen in other sports. Previous studies of people with type I diabetes have shown an increase in adverse events at altitude, including retinal hemorrhage, hypoglycemia, and ketoacidosis. This study set out to determine if there are changes in vital indices, including heart rate and blood pressure, alterations in blood gases, metabolic changes, and symptoms of acute mountain sickness as compared to nondiabetic controls.
Six climbers with type I diabetes and 10 controls were enrolled in the study as part of an expedition to Cho Oyu in the Himalayas (summit altitude 8201 m). The climbers with diabetes were free of retinopathy, peripheral vascular disease, microalbuminuria, ischemic heart disease (or other ECG abnormalities), and hypertension and all had good diabetic control as defined by the ADA. All of the diabetic climbers and 8 of the 10 controls had experience at extreme altitudes, and the 2 controls without extreme altitude experience had previously done endurance trekking. Blood pressure (BP), venous blood gases, capillary blood glucose, and heart rate were measured both before and 4 hours after trekking from elevations of 0, 3700, and 5800 m. Dilated eye exams, plasma insulin, 12-hour urinary albumin excretion, and cholesterol and C-peptide levels were all checked before and after the expedition. Acute mountain sickness (AMS) was assed by the Lake Louise scoring system at 1700, 3700, and 5800 m.
There was no significant difference in the elevation that was ultimately attained or in the AMS scores between the 2 groups. None of the climbers with diabetes developed retinal hemorrhages or albuminuria. Heart rate did increase significantly in both groups at the higher elevations as compared to sea level. Mean blood pressure did not significantly change with elevation, but there was a significant increase in systolic and diastolic pressures postexertion at 0 m for both groups and 3700 m for the controls. At 5800 m the controls had a significant decrease in BP after trekking, while there was no significant change within the group with diabetes. It is important to mention, however, that at each elevation studied there was no significant difference in the heart rate or BP between the group with diabetes and the controls. The glucose levels were significantly elevated in the group with diabetes compared to controls at all elevations. Glucose levels did not significantly change with elevation in the group with diabetes, likely due to active monitoring and insulin administration, while the levels did increase at higher elevations in the control group. Insulin requirements of the group with diabetes did significantly increase with elevation particularly between 0 and 4200 m. There were no other metabolic or respiratory measures that differed between the 2 groups.
The authors conclude that well-trained, healthy people with type I diabetes are not at a greater risk of changes in their vital indices or metabolic status as long as they maintain rigorous glucose control when going to extreme altitudes. This paper reinforces that climbers with diabetes have similar AMS scores compared to controls at all elevations. Their explanation for the absence of severe diabetic complications in this study (retinal hemorrhages, ketoacidosis) as compared to previously published data is the superior fitness level and experience of the climbers with diabetes prior to the expedition. It is important for physicians working with insulin-dependent climbers to stress the need for physical preparation as well as the special diligence needed for glucose control while at extreme elevations.
(Med Sci Sports Exerc. 2004;36(8):1283–1289) P Pavan, P Sarto, L Merlo, et al. Prepared by Christopher Olivares Oregon Health & Science University, Portland, OR, USA
American Journal of Tropical Medicine and Hygiene
Impact of Snake Bites and Determinants of Fatal Outcomes in Southeastern Nepal
The Terai region of Nepal is an arid, agricultural region in Southeastern Nepal. Snakebite is a fairly common cause of significant morbidity and mortality in this and other regions (20 000 bites per year with 1000 deaths per year); however, formal statistics about this public health problem have never been collected and analyzed. These authors set out to collect information from snakebite victims and their families in order to specify risk factors and to develop public health interventions to lessen future morbidity and mortality.
The authors designed this study as a community-based survey in which 1817 households were chosen randomly to undergo an official survey. All households underwent questioning about any snakebites occurring in the previous 14 months and included specific demographics about the victim, the snakebite, its management, immediate medical and long-term outcome, and any economic burden to the family.
A total of 143 snakebites were found within the 1817 households, of which there were 20 fatalities. The majority of victims were males who worked in agriculture, and most bites occurred outside during the rainy season. Snake type could be positively identified by 61% of victims, and were reported as mostly cobras, water snakes, and kraits. Those with fatal envenomations were likely to be bitten inside their home between the hours of midnight and 6
Although this study was weakened by its retrospective methods, and undoubtedly had some recall bias, it does show several areas where a public health intervention could benefit the Nepali people. Education regarding the need for rapid transport of victims as well as instruction in the use of pressure-immobilization splints might improve outcomes in snakebite victims. Even more important would be an increased availability of antivenom in rural areas.
(Am J Trop Med Hyg. 2004;71(2):234–238) SK Sharma, F Chappuis, N Jha, et al. Prepared by Karen Nolan Kuehl, MD Oregon Health & Science University, Portland, OR, USA
Irish Medical Journal
Air Travel in Pregnancy: The Air-Born Study
This study was designed by a group of Irish obstetrician-gynecologists after recognizing the lack of a consensus on air travel in the pregnant patient. Although physicians should be consulted prior to all antenatal flights, past studies have shown that commercial air flight is safe in most uncomplicated pregnancies, and most physicians allow flying until 36 weeks. However, patients with risk of preterm labor or complicating factors should not fly. This study was designed to define the regulations of the airline industry with respect to pregnant customers.
The authors sent questionnaires to 68 international airlines. Each airline was questioned about airline policy regarding pregnancy in passengers and crew, capacity to deal with obstetric emergencies, and details about those specific emergencies. In addition, some respondents included detailed anecdotal information about in-flight obstetric emergencies.
Questionnaires were received from only 17 of 68 airlines (25%). All airlines prevented crewmembers from flying after the first trimester, and 82% prevented pregnant pilots from flying after the first trimester. Three airlines had no restrictions against pregnant passengers. Fourteen airlines had restrictions on pregnant passengers after 28 to 36 weeks. However, 9 of the 14 airlines had specific conditions that could be met to allow travel up until the due date. Forty-one percent of airlines had no guidelines for dealing with pregnant passengers arriving at the boarding area, and only 29% carried a full delivery kit that included oxytocin and a neonatal oxygen mask. Seventy percent of airlines provided some training regarding in-flight delivery, and 65% had experienced some sort of in-flight obstetric emergency.
There are many theoretical dangers of flying during pregnancy, including preterm labor, deep venous thrombosis, and increased nausea. In-flight obstetric emergencies could lead to significant maternal and perinatal risk and are terrifying events when they do occur. Despite the risk, very few airlines responded to this study questionnaire, and of the respondents, it was found that airline policy concerning obstetric emergencies and pregnant patients is extremely limited. An educational campaign aimed at airlines worldwide could help address a potential public health problem and might encourage more airlines to develop formal policy about pregnant employees and passengers.
(Ir Med J. 2004;97(6):167–168) F Breathnach, T Geoghegan, S Daly, and MJ Turner. Prepared by Karen Nolan Kuehl, MD Oregon Health & Science University, Portland, OR, USA