Joel G. Ray

Maternal body mass index and the risk of preeclampsia: a systematic overview.

Background. Maternal obesity, both in itself and as part of the insulin resistance syndrome, is an important risk factor for the development of preeclampsia. Accurately quantifying the relation between prepregnancy maternal body mass index and the risk of preeclampsia may better identify those at highest risk. We performed a systematic overview of the literature to determine the association between prepregnancy body mass index and the risk of preeclampsia. Methods. Two reviewers independently retrieved all relevant English language cohort studies through a systematic search of Medline and Embase between 1980 and June 2002. Study data were abstracted in a similar fashion. For each study, the risk ratio of preeclampsia was calculated by comparing the risk of preeclampsia among women with the highest body mass index with those with the lowest. Results. We identified thirteen cohort studies, comprising nearly 1.4 million women. The risk of preeclampsia typically doubled with each 5–7 kg/m2 increase in prepregnancy body mass index. This relation persisted in studies that excluded women with chronic hypertension, diabetes mellitus or multiple gestations, or after adjustment for other confounders. Conclusions. Most observational studies demonstrate a consistently strong positive association between maternal prepregnancy body mass index and the risk of preeclampsia. Increasing obesity in developed countries is likely to increase the occurrence of preeclampsia. Consideration should be given to the potential benefits of prepregnancy weight reduction programs.

Cardiovascular health after maternal placental syndromes (CHAMPS): population-based retrospective cohort study

BACKGROUND Maternal placental syndromes, including the hypertensive disorders of pregnancy and abruption or infarction of the placenta, probably originate from diseased placental vessels. The syndromes arise most often in women who have metabolic risk factors for cardiovascular disease, including obesity, pre-pregnancy hypertension, diabetes mellitus, and dyslipidaemia. Our aim was to assess the risk of premature vascular disease in women who had had a pregnancy affected by maternal placental syndromes. METHODS We did a population-based retrospective cohort study in Ontario, Canada, of 1.03 million women who were free from cardiovascular disease before their first documented delivery. We defined the following as maternal placental syndromes: pre-eclampsia, gestational hypertension, placental abruption, and placental infarction. Our primary endpoint was a composite of cardiovascular disease, defined as hospital admission or revascularisation for coronary artery, cerebrovascular, or peripheral artery disease at least 90 days after the delivery discharge date. FINDINGS The mean (SD) age of participants was 28.2 (5.5) years at the index delivery, and 75 380 (7%) women were diagnosed with a maternal placental syndrome. The incidence of cardiovascular disease was 500 per million person-years in women who had had a maternal placental syndrome compared with 200 per million in women who had not (adjusted hazard ratio [HR] 2.0, 95 CI 1.7-2.2). This risk was higher in the combined presence of a maternal placental syndrome and poor fetal growth (3.1, 2.2-4.5) or a maternal placental syndrome and intrauterine fetal death (4.4, 2.4-7.9), relative to neither. INTERPRETATION The risk of premature cardiovascular disease is higher after a maternal placental syndrome, especially in the presence of fetal compromise. Affected women should have their blood pressure and weight assessed about 6 months postpartum, and a healthy lifestyle should be emphasised.

Chronic dialysis and death among survivors of acute kidney injury requiring dialysis.

CONTEXT Severe acute kidney injury among hospitalized patients often necessitates initiation of short-term dialysis. Little is known about the long-term outcome of those who survive to hospital discharge. OBJECTIVE To assess the risk of chronic dialysis and all-cause mortality in individuals who experience an episode of acute kidney injury requiring dialysis. DESIGN, SETTING, AND PARTICIPANTS We conducted a population-based cohort study of all adult patients in Ontario, Canada, with acute kidney injury who required in-hospital dialysis and survived free of dialysis for at least 30 days after discharge between July 1, 1996, and December 31, 2006. These individuals were matched with patients without acute kidney injury or dialysis during their index hospitalization. Matching was by age plus or minus 5 years, sex, history of chronic kidney disease, receipt of mechanical ventilation during the index hospitalization, and a propensity score for developing acute kidney injury requiring dialysis. Patients were followed up until March 31, 2007. MAIN OUTCOME MEASURES The primary end point was the need for chronic dialysis and the secondary outcome was all-cause mortality. RESULTS We identified 3769 adults with acute kidney injury requiring in-hospital dialysis and 13 598 matched controls. The mean age was 62 years and median follow-up was 3 years. The incidence rate of chronic dialysis was 2.63 per 100 person-years among individuals with acute kidney injury requiring dialysis, and 0.91 per 100 person-years among control participants (adjusted hazard ratio, 3.23; 95% confidence interval, 2.70-3.86). All-cause mortality rates were 10.10 and 10.85 per 100 person-years, respectively (adjusted hazard ratio, 0.95; 95% confidence interval, 0.89-1.02). CONCLUSIONS Acute kidney injury necessitating in-hospital dialysis was associated with an increased risk of chronic dialysis but not all-cause mortality.

Bias in published cost effectiveness studies: systematic review

Abstract Objective To investigate if published studies tend to report favourable cost effectiveness ratios (below

Homocysteine-Lowering Therapy and Stroke Risk, Severity, and Disability. Additional Findings From the HOPE 2 Trial

20 000,

Vitamin B12 and the risk of neural tube defects in a folic-acid-fortified population.

50 000, and

Brief overview of maternal triglycerides as a risk factor for pre‐eclampsia

100 000 per quality adjusted life year (QALY) gained) and evaluate study characteristics associated with this phenomenon. Design Systematic review. Studies reviewed 494 English language studies measuring health effects in QALYs published up to December 2001 identified using Medline, HealthSTAR, CancerLit, Current Content, and EconLit databases. Main outcome measures Incremental cost effectiveness ratios measured in dollars set to the year of publication. Results Approximately half the reported incremental cost effectiveness ratios (712 of 1433) were below

Greater maternal weight and the ongoing risk of neural tube defects after folic acid flour fortification.

20 000/QALY. Studies funded by industry were more likely to report cost effectiveness ratios below

Evidence for suboptimal use of periconceptional folic acid supplements globally

20 000/QALY (adjusted odds ratio 2.1, 95% confidence interval 1.3 to 3.3),

Folic acid food fortification is associated with a decline in neuroblastoma

50 000/QALY (3.2, 1.8 to 5.7), and