Hypertensive disorders of pregnancy and future health and mortality: a record linkage study

The objective of this register-based cohort study was to examine the relationship between hypertensive disorders of pregnancy and future hospital discharges from specified causes including cardiovascular disease, incident cancer registrations and mortality. From the Aberdeen Maternity and Neonatal Databank we identified 34,854 women who were born on or before 31st December 1967 and who had (i) preeclampsia/eclampsia, (ii) gestational hypertension or (iii) normal blood pressure in their first pregnancy. Hospital discharges from selected causes including cardiovascular disease, cancer registrations and deaths in these women were identified from the Scottish Morbidity Records. There were 2026 women who had preeclampsia, 8891 who had gestational hypertension and 23,937 who were normotensive during their first pregnancy. Compared to normotensive women, women with preeclampsia had a higher mortality from ischaemic heart disease (adj. IRR 1.38, 95% CI 1.03, 1.84) and circulatory disease (adj. IRR 1.30, 95% CI 1.06, 1.60). Similar trends were seen with gestational hypertension. There was no difference in all cause mortality in the three groups. The odds of a hypertensive episode were higher in women with preeclampsia (adj. OR 1.79, 95% CI 1.55, 2.05) and gestational hypertension (adj. OR 1.68, 95% CI 1.55, 1.82) compared to normotensives. Compared to normotensives, women with gestational hypertension (adj. IRR 0.91, 95% CI 0.85, 0.96) or preeclampsia (adj. IRR 0.86, 95% CI 0.77, 0.97) had lower incidences of cancer. Women with pregnancy induced hypertension are at a higher risk of incidence and mortality from ischaemic heart disease and a lower risk of cancer

Hypertensive diseases of pregnancy and risk of hypertension and stroke in later life: results from cohort study

Objective: To examine the association between hypertensive diseases of pregnancy (gestational hypertension and pre-eclampsia) and the development of circulatory diseases in later life. Design: Cohort study of women who had pre-eclampsia during their first singleton pregnancy. Two comparison groups were matched for age and year of delivery, one with gestational hypertension and one with no history of raised blood pressure. Setting: Maternity services in the Grampian region of Scotland. Participants: Women selected from the Aberdeen maternity and neonatal databank who were resident in Aberdeen and who delivered a first, live singleton from 1951 to 1970. Main outcome measures: Current vital and cardiovascular health status ascertained through postal questionnaire survey, clinical examination, linkage to hospital discharge, and mortality data. Results: There were significant positive associations between pre-eclampsia/eclampsia or gestational hypertension and later hypertension in all measures. The adjusted relative risks varied from 1.13-3.72 for gestational hypertension and 1.40-3.98 for pre-eclampsia or eclampsia. The adjusted incident rate ratio for death from stroke for the pre-eclampsia/eclampsia group was 3.59 (95% confidence interval 1.04 to 12.4). Conclusions: Hypertensive diseases of pregnancy seem to be associated in later life with diseases related to hypertension. If greater awareness of this association leads to earlier diagnosis and improved management, there may be scope for reducing a proportion of the morbidity and mortality from such diseases

Exploration of Global Health Careers Across the Medical Fields

BackgroundDespite expansion of interest among American medical students in global health (GH), academic medical centers face multiple obstacles to the development of structured GH curricula and career guidance. To meet these demands we sought to provide a systematic analysis of the accounts of GH experts.MethodsWe developed a collaborative, interview-based, qualitative analysis of GH experiences across six career-related themes that are relevant to medical students interested in GH: justification, medical education, economics, research prospects, law and ethics, and work-life balance. Seven GH faculty members were interviewed for 30-90 minutes using sample questions as guidelines. We applied a grounded theory approach to analyze the interview transcripts to discover an emerging theory pertinent to GH trainees.FindingsRegarding 'justification,' 4 respondents defined GH as work with the underserved irrespective of geographic location; 5 respondents found sustainability imperative; and all respondents believe GH creates better physicians. Respondents identified many physician competencies developed through GH 'medical education,' with 5 respondents agreeing that work with underserved populations has transformative potential. Concerning 'economics', 3 respondents acknowledged GH's popularity among trainees, resulting in increased training opportunities, and 2 respondents emphasized an associated deficiency in program quality. All respondents described career models across specialties. Four respondents noted funding challenges when discussing 'research prospects'. Within the theme of 'laws and ethics', 4 respondents perceived inadequate accountability, and 6 respondents identified ways to create accountability. Finally, 6 respondents recognized family demands can compromise one's GH career and thus 'work-life balance'.ConclusionDespite diverse perspectives on the meaning and sustainability of GH work, this analysis provides a nascent framework that may inform curricular development for GH trainees. Suggestions are offered for elaborating this framework to fully exploit the transformative potential of GH training in medical education

Long-Term Results from a Randomised Controlled Trial (RCT) Of Telephone Delivered Cognitive Behaviour Therapy (TCBT) And Exercise In The Management Of Chronic Widespread Pain (CWP), And Predictors Of Treatment-Effectiveness

BackgroundChronic Widespread Pain (CWP), the primary symptom associated with fibromyalgia, has been shown to persist over time. It is challenging to manage and can have impacts on functioning and quality of life. Recent reviews have, however, suggested that non-pharmacological treatments such as behaviour therapy and exercise may be effective, at least for short-term management. The MUSICIAN study was a trial of 6-month courses of treatment by telephone-delivered cognitive behavioural therapy (tCBT), exercise, or a combination of both for the management of CWP that have previously shown short-term improvements in patient-reported health compared to treatment as usual (TAU). The aim of the current study is to determine whether these improvements are maintained long-term (2 years after the end of treatment), to determine if any of the active treatments were cost-effective in relation to TAU, and to determine if pre-treatment characteristics identify patients who are more likely to benefit from these treatments.MethodsPopulation survey was used to identify patients who: met the American College of Rheumatology (ACR) definition of CWP, consulted a GP for pain in the last year, and had no contraindications for exercise. Random assignation was to: a) 8 weekly sessions of tCBT, with refreshers at 3 and 6 months; b) an individually tailored exercise programme with monthly review over 6 months; c) both active treatments, or d) TAU. Follow-ups were at end of treatment, and 3 and 24 months later. Primary outcome was self-reported change in health since before the trial. Positive outcomes were Much better or Very much better, on a 7-point scale from Very much worse to Very much better. Analysis was by longitudinal logistic regression. Results are presented as odds ratios (OR) with 95% Confidence Intervals (CI). Additional models were run to assess cost-effectiveness, and the influence of baseline characteristics on the effectiveness of each treatment.Results442 persons (median age 57 years, 57% female) were randomised of which 361 (82%) provided information 24 months post-treatment. The percentage of patients reporting positive outcome at the final follow-up was: TAU 12.8%, tCBT 35.4%, exercise 29.4%, and combined treatment 31.2%. At 24 months, positive outcome after adjustment for baseline characteristics was more likely for tCBT (OR 3.6; 95% CI 1.7, 7.6), exercise (2.5; 1.2, 5.4), and combined treatment (2.9; 1.4, 6.0) compared to TAU. Of all four groups, tCBT had highest probability of being cost-effective at a ceiling willingness to pay ratio of £20,000 per Quality Adjusted Life Year gained. Baseline characteristics associated with greater response to tCBT at any time-point were high psychological distress (treatment-predictor interaction OR 5.6; 1.5, 21.2), and high kinesiophobia (4.7; 1.1, 20.5). High Chronic Pain Grade at baseline was significantly associated with a greater response to Combined Treatment (8.3; 1.6, 43.4).ConclusionA six-month programme of exercise or tCBT is associated with improvements in health in CWP patients which are maintained two years after treatment has finished. The size of effect is similar for both treatments, and there is no advantage in receiving both treatments together. Characteristics were identified associated with response to the treatments which could allow future targeting of such interventions to those likely to benefit.BackgroundChronic Widespread Pain (CWP), the primary symptom associated with fibromyalgia, has been shown to persist over time. It is challenging to manage and can have impacts on functioning and quality of life. Recent reviews have, however, suggested that non-pharmacological treatments such as behaviour therapy and exercise may be effective, at least for short-term management. The MUSICIAN study was a trial of 6-month courses of treatment by telephone-delivered cognitive behavioural therapy (tCBT), exercise, or a combination of both for the management of CWP that have previously shown short-term improvements in patient-reported health compared to treatment as usual (TAU). The aim of the current study is to determine whether these improvements are maintained long-term (2 years after the end of treatment), to determine if any of the active treatments were cost-effective in relation to TAU, and to determine if pre-treatment characteristics identify patients who are more likely to benefit from these treatments.MethodsPopulation survey was used to identify patients who: met the American College of Rheumatology (ACR) definition of CWP, consulted a GP for pain in the last year, and had no contraindications for exercise. Random assignation was to: a) 8 weekly sessions of tCBT, with refreshers at 3 and 6 months; b) an individually tailored exercise programme with monthly review over 6 months; c) both active treatments, or d) TAU. Follow-ups were at end of treatment, and 3 and 24 months later. Primary outcome was self-reported change in health since before the trial. Positive outcomes were Much better or Very much better, on a 7-point scale from Very much worse to Very much better. Analysis was by longitudinal logistic regression. Results are presented as odds ratios (OR) with 95% Confidence Intervals (CI). Additional models were run to assess cost-effectiveness, and the influence of baseline characteristics on the effectiveness of each treatment.Results442 persons (median age 57 years, 57% female) were randomised of which 361 (82%) provided information 24 months post-treatment. The percentage of patients reporting positive outcome at the final follow-up was: TAU 12.8%, tCBT 35.4%, exercise 29.4%, and combined treatment 31.2%. At 24 months, positive outcome after adjustment for baseline characteristics was more likely for tCBT (OR 3.6; 95% CI 1.7, 7.6), exercise (2.5; 1.2, 5.4), and combined treatment (2.9; 1.4, 6.0) compared to TAU. Of all four groups, tCBT had highest probability of being cost-effective at a ceiling willingness to pay ratio of £20,000 per Quality Adjusted Life Year gained. Baseline characteristics associated with greater response to tCBT at any time-point were high psychological distress (treatment-predictor interaction OR 5.6; 1.5, 21.2), and high kinesiophobia (4.7; 1.1, 20.5). High Chronic Pain Grade at baseline was significantly associated with a greater response to Combined Treatment (8.3; 1.6, 43.4).ConclusionA six-month programme of exercise or tCBT is associated with improvements in health in CWP patients which are maintained two years after treatment has finished. The size of effect is similar for both treatments, and there is no advantage in receiving both treatments together. Characteristics were identified associated with response to the treatments which could allow future targeting of such interventions to those likely to benefit

Markers of endothelial activation and atherothrombosis in women with history of preeclampsia or gestational hypertension

Women who have had preeclampsia (PE) or gestational hypertension (GH) exhibit relatively high rates of circulatory diseases. PE is a disease associated with inflammation and vascular endothelial dysfunction. We therefore hypothesised that women with a history of PE or GH might have abnormal levels of markers of endothelial activation or inflammation, reflecting either an innate predisposition to preeclampsia or changes induced by the eclamptic process. Levels of von Willebrand factor, fibrinogen and C-reactive protein were compared in 392 women with a history of PE between 1951 and 1970, 297 women with a history of GH and 163 matched controls. Although no significant differences between those with either PE or GH and controls were noted, subjects with a history of PE had significantly higher CRP values than those with GH. No significant differences were found when the three groups were compared for von Willebrand factor or fibrinogen. Overall, the data do not support our hypothesis. In addition, our data document increasing von Willebrand factor levels increase with age, which may help explain the age dependent increase in venous or arterial thrombosis. Moderate alcohol consumption was also associated with lower levels of inflammatory markers