CONTEXT\nHypertension is associated with a significantly increased risk of morbidity and mortality. Only diuretics and beta-blockers have been shown to reduce this risk in long-term clinical trials. Whether newer antihypertensive agents reduce the incidence of cardiovascular disease (CVD) is unknown.\n\n\nOBJECTIVE\nTo compare the effect of doxazosin, an alpha-blocker, with chlorthalidone, a diuretic, on incidence of CVD in patients with hypertension as part of a study of 4 types of antihypertensive drugs: chlorthalidone, doxazosin, amlodipine, and lisinopril.\n\n\nDESIGN\nRandomized, double-blind, active-controlled clinical trial, the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial, initiated in February 1994. In January 2000, after an interim analysis, an independent data review committee recommended discontinuing the doxazosin treatment arm based on comparisons with chlorthalidone. Therefore, outcomes data presented herein reflect follow-up through December 1999.\n\n\nSETTING\nA total of 625 centers in the United States and Canada.\n\n\nPARTICIPANTS\nA total of 24,335 patients (aged > or = 55 years) with hypertension and at least 1 other coronary heart disease (CHD) risk factor who received either doxazosin or chlorthalidone.\n\n\nINTERVENTIONS\nParticipants were randomly assigned to receive chlorthalidone, 12.5 to 25 mg/d (n=15,268), or doxazosin, 2 to 8 mg/d (n=9067), for a planned follow-up of 4 to 8 years.\n\n\nMAIN OUTCOME MEASURES\nThe primary outcome measure was fatal CHD or nonfatal myocardial infarction (MI), analyzed by intent to treat; secondary outcome measures included all-cause mortality, stroke, and combined CVD (CHD death, nonfatal MI, stroke, angina, coronary revascularization, congestive heart failure [CHF], and peripheral arterial disease); compared by the chlorthalidone group vs the doxazosin group.\n\n\nRESULTS\nMedian follow-up was 3.3 years. A total of 365 patients in the doxazosin group and 608 in the chlorthalidone group had fatal CHD or nonfatal MI, with no difference in risk between the groups (relative risk [RR], 1.03; 95% confidence interval [CI], 0.90-1.17; P=.71). Total mortality did not differ between the doxazosin and chlorthalidone arms (4-year rates, 9.62% and 9.08%, respectively; RR, 1.03; 95% CI, 0.90-1.15; P=.56.) The doxazosin arm, compared with the chlorthalidone arm, had a higher risk of stroke (RR, 1.19; 95% CI, 1.01-1.40; P=.04) and combined CVD (4-year rates, 25.45% vs 21.76%; RR, 1.25; 95% CI, 1.17-1.33; P<.001). Considered separately, CHF risk was doubled (4-year rates, 8.13% vs 4.45%; RR, 2.04; 95% CI, 1.79-2.32; P<.001); RRs for angina, coronary revascularization, and peripheral arterial disease were 1.16 (P<.001), 1.15 (P=.05), and 1.07 (P=.50), respectively.\n\n\nCONCLUSION\nOur data indicate that compared with doxazosin, chlorthalidone yields essentially equal risk of CHD death/nonfatal MI but significantly reduces the risk of combined CVD events, particularly CHF, in high-risk hypertensive patients.

Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: The antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT)

Obesity is rising in the obstetric population, yet there is an absence of services and guidance for the management of maternal obesity. This systematic review aimed to investigate relationships between obesity and impact on obstetric care. Literature was systematically searched for cohort studies of pregnant women with anthropometric measurements recorded within 16-weeks gestation, followed up for the term of the pregnancy, with at least one obese and one comparison group. Two researchers independently data-extracted and quality-assessed each included study. Outcome measures were those that directly or indirectly impacted on maternity resources. Primary outcomes included instrumental delivery, caesarean delivery, duration of hospital stay, neonatal intensive care, neonatal trauma, haemorrhage, infection and 3rd/4th degree tears. Meta-analysis shows a significant relationship between obesity and increased odds of caesarean and instrumental deliveries, haemorrhage, infection, longer duration of hospital stay and increased neonatal intensive care requirement. Maternal obesity significantly contributes to a poorer prognosis for mother and baby during delivery and in the immediate post-partum period. National clinical guidelines for management of obese pregnant women, and public health interventions to help safeguard the health of mothers and their babies are urgently required.

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The impact of maternal BMI status on pregnancy outcomes with immediate short-term obstetric resource implications: a meta-analysis.

Summary
Despite numerous studies reporting an increased risk of cesarean delivery among overweight or obese compared with normal weight women, the magnitude of the association remains uncertain. Therefore, we conducted a meta-analysis of the current literature to provide a quantitative estimate of this association. We identified studies from three sources: (i) a PubMed search of relevant articles published between January 1980 and September 2005; (ii) reference lists of publications selected from the search; and (iii) reference lists of review articles published between 2000 and 2005. We included cohort designed studies that reported obesity measures reflecting pregnancy body mass, had a normal weight comparison group, and presented data allowing a quantitative measurement of risk. We used a Bayesian random effects model to perform the meta-analysis and meta-regression. Thirty-three studies were included. The unadjusted odd ratios of a cesarean delivery were 1.46 [95% confidence interval (CI): 1.34–1.60], 2.05 (95% CI: 1.86–2.27) and 2.89 (95% CI: 2.28–3.79) among overweight, obese and severely obese women, respectively, compared with normal weight pregnant women. The meta-regression found no evidence that these estimates were affected by selected study characteristics. Our findings provide a quantitative estimate of the risk of cesarean delivery associated with high maternal body mass.

Maternal obesity and risk of cesarean delivery: a meta-analysis.

Object Many patients undergoing elective thoracic or lumbar fusion procedures are obese, but the contribution of obesity to complications in spine surgery has not been defined. The authors retrospectively assessed the prevalence of obesity in a cohort of patients undergoing thoracic and lumbar fusion and correlate the presence of obesity with the incidence of operative complications. Methods A retrospective review of consecutive patients treated by a single surgeon (J.K.R.) over a 36-month period at either Rush University Medical Center or the Neurological and Orthopedic Institute of Chicago was performed. The authors identified 332 elective thoracic and lumbar spine surgery cases; the cohort was restricted to include only patients with symptomatic degenerative conditions in need of an anterior, posterior, or combined anterior–posterior fusion. Cases of trauma, tumor, and infection and any case in which the procedure was performed for emergency indications were excluded. A total of 97 cases were identifie...

Obesity and spine surgery: relation to perioperative complications

Methods We followed the MOOSE consensus statement. We searched MEDLINE and EMBASE from their inceptions. We included studies that assessed the effect of maternal underweight compared with normal weight according to body mass index in singleton gestations on our two primary outcomes: PTB (<37 weeks) and LBW (<2500 g). Two assessors independently reviewed citations, extracted data and assessed quality. Results A total of 78 studies were included involving 1 025 794 women. The overall risk of PTB was increased in the cohort studies of underweight women [adjusted relative risk (RR) 1.29, 95% confidence interval (CI) 1.15–1.46], as were the risks of spontaneous PTB (adjusted RR 1.32, 95% CI 1.10–1.57) and induced PTB (adjusted RR 1.21, 95% CI 1.07–1.36). Underweight women had an increased risk of an LBW infant (adjusted RR 1.64, 95% CI 1.38–1.94). In developed countries, underweight women had an increased risk of PTB (RR 1.22, 95% CI 1.15–1.30) but not in developing countries (RR 0.99, 95% CI 0.67–1.45). In both developed and developing countries, underweight women were at increased risk of having an LBW infant (RR 1.48, 95% CI 1.29–1.68, and RR 1.52, 95% CI 1.25–1.85, respectively). Conclusions In this systematic review and meta-analyses, we determined that singletons born to underweight women have higher risks of PTB (overall, spontaneous and induced) and LBW than those born to women with normal weight.

/pdf/maternal-underweight-and-the-risk-of-preterm-birth-and-low-1xzszuobz6.pdf

Maternal underweight and the risk of preterm birth and low birth weight: a systematic review and meta-analyses

Background. To investigate the influence of Body Mass Index on the incidence of labor complications in a population of women with a normal pregnancy. Material and methods. From a local database, information on maternal weight and height was extracted concerning 4258 women who had an uncomplicated pregnancy. After calculation and stratification with respect to Body Mass Index, this was retrospectively related to labor interventions and complications. Results. High Body Mass Index was related to more oxytocin infusion and early amniotomy, but not to vacuum extraction or cesarean section. Primary inertia and, to a minor degree, cephalopelvic disproportion and secondary inertia were seen more often in women with high Body Mass Index. Conclusions. Overweight (25.0 =30.0) are only weak predictors of labor complications, given a normal pregnancy. However, the heavy use of labor augmentation indicates that obese women should not be recommended to give birth in an ABC-clinic or at home.

https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1034/j.1600-0412.1999.780911.x

The influence of prepregnancy body mass index on labor complications.

Aim of study. To investigate the association between obesity and peri- or postoperative complications after hysterectomy for nonmalignant bleeding disorders. Material and methods. Data from 444 vaginal hysterectomies and 503 abdominal hysterectomies indicated by benign bleeding disorders were drawn from a regional database. Data on peri- or postoperative complications and postoperative stay were related to preoperative body mass index (BMI). Results. Obesity was related to longer operation time for vaginal as well as abdominal hysterectomy and to large perioperative blood loss for vaginal hysterectomy only. No association was found between BMI and serious complications such as ileus, infection or hematomas except for a higher prevalence of wound hematoma after abdominal hysterectomy in underweight and normal weight patients. Neither was any association found between BMI and use of blood transfusion, reoperation or prolonged postoperative stay. Conclusion. Vaginal and abdominal hysterectomy have a signific...

https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1600-0412.2004.00285.x

The influence of body mass index on the prevalence of complications after vaginal and abdominal hysterectomy

In fifteen patients with hypertension, inadequately controlled during treatment with propranolol alone (mean dosage 333 mg/day), plasma volume (PV) and extracellular fluid volume (ECV) were determined. After addition of prazosin for 3 months (mean dosage 9 mg/day) there was a significant increase in PV and ECV, on average 8 and 5%, respectively. The decrease in supine blood pressure, systolic as well as diastolic, was very modest, on average 11 mmHg (SD±12) and 4 mmHg (SD ± 7), respectively. The changes in standing blood pressure were more pronounced. It is assumed that the expansion of PV and ECV contributes to the inadequate blood pressure response found in the present study.

Changes in plasma volume and extracellular fluid volume after addition of prazosin to propranolol treatment in patients with hypertension.

. In 16 patients with hypertension, BP could not be controlled satisfactorily by treatment with propranolol alone (mean dosage 325 mg/day). Plasma volume (PV) (T-1824) and extracellular fluid volume (ECV) (82Br-distribution space) were determined in these patients before and after the addition of hydralazine for three months (mean dosage 135 mg/day). After the addition of hydralazine, PV and ECV increased significantly, by 9% and 3%, respectively. Systolic and diastolic BPs decreased, by 15% and 13%. The mechanisms inducing fluid retention during treatment with hydralazine and the clinical significance of the problem are discussed. It is concluded that the addition of a diuretic to propranolol-hydralazine treatment is often well indicated.

Changes in Plasma Volume and Extracellular Fluid Volume after Addition of Hydralazine to Propranolol Treatment in Patients with Hypertension

A caw of total puerperal rupture of the pubic symphysis during non-operative delivery is rcportcd and the literature reviewed. The patient in our case was successfully treated by external skeletal fixation. In agreement with the literature the authors recommend external skeletal fixation when lesions are unstable, when inadequate reduction is achieved. or when the diastasis is more than 40 mm.

Kjeld Leisgaard Rasmussen

Papers

The influence of prepregnancy body mass index on labor complications.

The influence of body mass index on the prevalence of complications after vaginal and abdominal hysterectomy

Changes in plasma volume and extracellular fluid volume after addition of prazosin to propranolol treatment in patients with hypertension.

Changes in Plasma Volume and Extracellular Fluid Volume after Addition of Hydralazine to Propranolol Treatment in Patients with Hypertension

External skeletal fixation as treatment for total puerperal rupture of the pubic symphysis.