Do improvements in clinical practice guidelines alter pregnancy outcomes in asthmatic women? A single-center retrospective cohort study

OBJECTIVE

Asthma occurs in ∼17% of Australian pregnancies and is associated with adverse perinatal outcomes, which worsen with poor asthma control . Consequently, the South Australian 'Asthma in Pregnancy' perinatal guidelines were revised in 2012 to address management according to severity. This study investigated if these revised guidelines reduced the impact of maternal asthma on risks of adverse perinatal outcomes before (Epoch 1, 2006-2011) and after the revision (Epoch 2, 2013-2018).

METHODS

Routinely collected perinatal and neonatal datasets from the Women's and Children's Hospital (Adelaide, Australia) were linked. Maternal asthma (prevalence:7.5%) was defined as asthma medication use or symptoms described to midwives. In imputation (n = 59131) and complete case datasets (n = 49594), analyses were conducted by inverse proportional weighting and multivariate logistic regression, accounting for confounders.

RESULTS

Overall, maternal asthma was associated with increased risks of any antenatal corticosteroid treatment for threatened preterm birth (aOR 1.319, 95% CI 1.078-1.614), any Caesarean section (aOR 1.196, 95% CI 1.059-1.351), Caesarean section without labor (aOR 1.241, 95% CI 1.067-1.444), intrauterine growth restriction (IUGR, aOR 1.285, 95% CI 1.026-1.61), and small for gestational age (aOR 1.324, 95% CI 1.136-1.542). After guideline revision, asthma-associated risks of any Caesarean section (p < 0.001), any antenatal corticosteroids (p = 0.041), and small for gestational age (p = 0.050), but not IUGR and Caesarean section without labour, were reduced.

CONCLUSIONS

Clinical practice guidelines based on the latest evidence do not guarantee clinical efficacy. Since adverse perinatal outcomes did not all improve, this work highlights the need to evaluate the ongoing impact of guidelines on clinical outcomes.

CD4 count and risk of anti-tuberculosis drug-associated cutaneous reactions in HIV-infected Thai patients

OBJECTIVES

Tuberculosis (TB) is a major cause of morbidity and mortality in human immunodeficiency virus (HIV) infected patients. However, anti-tuberculosis drugs can cause cutaneous adverse drug reactions (CADRs). This study was conducted to evaluate differences in CADR incidence between low and high CD4 cell count in patients with low and high CD4 cell count and to identify other risk factors for CADR in HIV-TB co-infected patients.

DESIGN

In a retrospective cohort of adult HIV-TB co-infected patients receiving standard anti-tuberculosis treatment between January 2008 and December 2015 at Vajira Hospital, Bangkok, Thailand, baseline demographic, clinical characteristics and factors associated with CADRs, including CD4 cell count status, were collected.

RESULTS

Of 307 patients enrolled, CADRs occurred in 48 during the 6-month period of anti-tuberculosis treatment (incidence rate 0.41 events/person-year). Maculopapular rash was the most prevalent CADR. Low CD4 cell count was not associated with CADRs. Cox regression analysis revealed that moderate decrease in the glomerular filtration rate, history of drug hypersensitivity and concomitant cotrimoxazole use were all associated with CADRs. Concomitant antiretroviral therapy use was associated with lower risk of CADRs. No difference in the time to CADRs between patients with lower and higher CD4 cell count could be demonstrated.

CONCLUSION

CADRs are common in HIV-TB co-infected patients. Early recognition and prompt withdrawal of the offending agent can prevent complications and improve TB care.

The highly abundant urinary metabolite urobilin interferes with the bicinchoninic acid assay

Estimation of total protein concentration is an essential step in any protein- or peptide-centric analysis pipeline. This study demonstrates that urobilin, a breakdown product of heme and a major constituent of urine, interferes considerably with the bicinchoninic acid (BCA) assay. This interference is probably due to the propensity of urobilin to reduce cupric ions (Cu(2+)) to cuprous ions (Cu(1+)), thus mimicking the reduction of copper by proteins, which the assay was designed to do. In addition, it is demonstrated that the Bradford assay is more resistant to the influence of urobilin and other small molecules. As such, urobilin has a strong confounding effect on the estimate of total protein concentrations obtained by BCA assay and thus this assay should not be used for urinary protein quantification. It is recommended that the Bradford assay be used instead.

Does Geijera parviflora Lindl. (Rutaceae) facilitate understorey species in semi-arid Australia?

Species composition under tree canopies often differs from that of surrounding micro-environments. In arid and semi-arid zones, trees can be beneficial to understorey vegetation. This study examined zones of vegetation composition and soil physiochemical parameters associated with Geijera parviflora Lindl. The importance of shade, rainfall redistribution, seed bank and soil moisture were examined. Species abundance, soil moisture, seed bank composition, rainfall redistribution and soil nutrient concentration were measured under five randomly selected mature G. parviflora trees in south-western New South Wales, Australia. To complement the findings from this study, artificial shade plots were constructed in a canopy-free area and species abundance measured seven months after shade construction. The study demonstrated that G. parviflora was associated with zonation of understorey vegetation. Two zones of understorey vegetation were found in relation to G. parviflora: (i) under the tree canopy with high species diversity, and (ii) beyond the canopy, this community being dominated by Dissocarpus paradoxus throughout the year with Crassula colorata appearing after rainfall. The zone beyond the canopy also had lower soil nutrient concentrations. Soil moisture, nutrient concentration and the seed bank density were significantly higher under the canopy. However, the canopy reduced precipitation reaching the soil surface. The effects of the canopy on understorey species composition and soil moisture were enhanced after winter rainfall. Artificial shade increased species abundance and richness under a 90%-shading treatment. The results indicated that G. parviflora generated spatial heterogeneity over the broader plant community increasing species richness, abundance and diversity under the canopy. This emphasises the importance of arid zone trees in conserving understorey plant diversity. Shading, soil nutrient concentration and increased seed bank density and soil moisture appeared to be key influences on the plant communities under the canopy.

A public perception of access to NHS dentistry

OBJECTIVE

To quantify the level of unmet dental access need which had been reported locally and to provide information about the perceived need for dental treatment with particular reference to those not registered for continuing NHS care.

DESIGN

A postal survey of adults resident in Aylesbury Vale, Buckinghamshire was carried out toward the end of 1994.

SUBJECTS AND METHODS

2000 adults aged between 35 and 54 years were randomly selected:

RESULTS

A response rate of 68% matched well with the population under study. 16% of people were unable to access any regular dental care and this group had the highest treatment need, with more experience of broken fillings and toothache within the previous year. 15% thought they were registered with an NHS dentist, but were not. Only 28% of all respondents were confirmed registered with an NHS dentist. 27% said they received private care, and one-third of these said it was because they had been unable to find an NHS dentist. In total, 74% of the population under study thought they were receiving regular dental care and only 6% did not want regular care. More than one-third of respondents volunteered comments about dental services. The majority were supportive of dentists but critical of the lack of NHS provision.

CONCLUSIONS

This survey indicates a substantial unmet perceived need in Aylesbury Vale, with more than one-third of this population unable to access continuing NHS dental services which they prefer. There is also a need for emergency and occasional dental treatment for a small proportion of this population. It is likely that a similar situation exists elsewhere in England.