BACKGROUND: Mental health conditions arising in the perinatal period, including depression, have the potential to impact negatively on not only the woman but also her partner, infant, and family. The capacity for routine, universal antenatal psychosocial assessment, and thus the potential for reduction of morbidity, is very significant. OBJECTIVES: To evaluate the impact of antenatal psychosocial assessment on perinatal mental health morbidity. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group`s Trials Register, the Cochrane Depression, Anxiety and Neurosis Group`s Trials Register (CCDAN TR-Studies), HSRProj in the National Library of Medicine (USA), and the Current Controlled Trials website: http://www.controlled trials.com/ and the UK National Research Register (last searched March 2008). SELECTION CRITERIA: Randomised and quasi-randomised controlled trials. DATA COLLECTION AND ANALYSIS: At least two review authors independently assessed trials for eligibility; they also extracted data from included trials and assessed the trials for potential bias. MAIN RESULTS: Two trials met criteria for an RCT of antenatal psychosocial assessment. One trial examined the impact of an antenatal tool (ALPHA) on clinician awareness of psychosocial risk, and the capacity of the antenatal ALPHA to predict women with elevated postnatal Edinburgh Depression Scale (EDS) scores, finding a trend towards increased clinician awareness of `high level` psychosocial risk where the ALPHA intervention had been used (relative risk (RR) 4.61 95% confidence interval (CI) 0.99 to 21.39). No differences between groups were seen for numbers of women with antenatal EDS scores, a score of greater than 9 being identified by ALPHA as of concern for depression (RR 0.69 95% CI 0.35 to 1.38); 139 providers. The other trial reported no differences in EPS scores greater than 12 at 16 weeks postpartum between the intervention (communication about the EDS scores with the woman and her healthcare providers plus a patient information booklet) and the standard care groups (RR 0.86 95% CI 0.61 to 1.21; 371 women). AUTHORS` CONCLUSIONS: While the use of an antenatal psychosocial assessment may increase the clinician`s awareness of psychosocial risk, neither of these small studies provides sufficient evidence that routine antenatal psychosocial assessment by itself leads to improved perinatal mental health outcomes. Further studies with better sample size and statistical power are required to further explore this important public health issue. It will also be important to examine outcomes up to one year postpartum not only for mother, but also infant and family.
 
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BACKGROUND: Evidence suggests that breastfeeding decreases the risk for many diseases in mothers and infants. It is therefore important to evaluate the effectiveness of breastfeeding interventions. PURPOSE: To systematically review evidence for the effectiveness of primary care-initiated interventions to promote breastfeeding with respect to breastfeeding and child and maternal health outcomes. DATA SOURCES: Electronic searches of MEDLINE, the Cochrane Central Register of Controlled Trials, and CINAHL from September 2001 to February 2008 and references of selected articles, restricted to English-language publications. STUDY SELECTION: Randomized, controlled trials of primary care-initiated interventions to promote breastfeeding, mainly in developed countries. DATA EXTRACTION: Characteristics of interventions and comparators, study setting, study design, population characteristics, the proportion of infants continuing breastfeeding by different durations, and infant or maternal health outcomes were recorded. DATA SYNTHESIS: Thirty-eight randomized, controlled trials (36 in developed countries) met eligibility criteria. In random-effects meta-analyses, breastfeeding promotion interventions in developed countries resulted in significantly increased rates of short- (1 to 3 months) and long-term (6 to 8 months) exclusive breastfeeding (rate ratios, 1.28 [95% CI, 1.11 to 1.48] and 1.44 [CI, 1.13 to 1.84], respectively). In subgroup analyses, combining pre- and postnatal breastfeeding interventions had a larger effect on increasing breastfeeding durations than either pre- or postnatal interventions alone. Furthermore, breastfeeding interventions with a component of lay support (such as peer support or peer counseling) were more effective than usual care in increasing the short-term breastfeeding rate. LIMITATIONS: Meta-analyses were limited by clinical and methodological heterogeneity. Reliable estimates for the isolated effects of each component of multicomponent interventions could not be obtained. CONCLUSION: Evidence suggests that breastfeeding interventions are more effective than usual care in increasing short- and long-term breastfeeding rates. Combined pre- and postnatal interventions and inclusion of lay support in a multicomponent intervention may be beneficial.
 
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BACKGROUND: Enteric fever (typhoid and paratyphoid fever) is potentially fatal. Infection with drug-resistant strains of the causative organism Salmonella enterica serovar Typhi or Paratyphi increases morbidity and mortality. Azithromycin may have better outcomes in people with uncomplicated forms of the disease. OBJECTIVES: To compare azithromycin with other antibiotics for treating uncomplicated enteric fever. SEARCH STRATEGY: In August 2008, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE, EMBASE, LILACS, and mRCT. We also searched conference proceedings, reference lists, and contacted researchers and a pharmaceutical company. SELECTION CRITERIA: Randomized controlled trials comparing azithromycin with other antibiotics for treating children and adults with uncomplicated enteric fever confirmed by cultures of S. Typhi or Paratyphi in blood and/or stool. DATA COLLECTION AND ANALYSIS: Both authors independently extracted data and assessed the risk of bias. Dichotomous data were presented and compared using the odds ratio, and continuous data were reported as arithmetic means with standard deviations and were combined using the mean difference (MD). Both were presented with 95% confidence intervals (CI). MAIN RESULTS: Seven trials involving 773 participants met the inclusion criteria. The trials used adequate methods to generate the allocation sequence and conceal allocation, and were open label. Three trials exclusively included adults, two included children, and two included both adults and children; all were hospital inpatients. One trial evaluated azithromycin against chloramphenicol and did not demonstrate a difference for any outcome (77 participants, 1 trial). When compared with fluoroquinolones in four trials, azithromycin significantly reduced clinical failure (OR 0.48, 95% CI 0.26 to 0.89; 564 participants, 4 trials) and duration of hospital stay (MD -1.04 days, 95% CI -1.73 to -0.34 days; 213 participants, 2 trials); all four trials included people with multiple-drug-resistant or nalidixic acid-resistant strains of S. Typhi or S. Paratyphi. We detected no statistically significant difference in the other outcomes. Compared with ceftriaxone, azithromycin significantly reduced relapse (OR 0.09, 95% CI 0.01 to 0.70; 132 participants, 2 trials) and not other outcome measures. Few adverse events were reported, and most were mild and self limiting. AUTHORS` CONCLUSIONS: Azithromycin appears better than fluoroquinolone drugs in populations that included participants with drug-resistant strains. Azithromycin may perform better than ceftriaxone.
 
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BACKGROUND: In 2002, the U.S. Preventive Services Task Force (USPSTF) recommended colorectal cancer screening for adults 50 years of age or older but concluded that evidence was insufficient to prioritize among screening tests or evaluate newer tests, such as computed tomographic (CT) colonography. PURPOSE: To review evidence related to knowledge gaps identified by the 2002 recommendation and to consider community performance of screening endoscopy, including harms. DATA SOURCES: MEDLINE, Cochrane Library, expert suggestions, bibliographic reviews. STUDY SELECTION: Eligible studies reported performance of colorectal cancer screening tests or health outcomes in average-risk populations and were at least of fair quality according to design-specific USPSTF criteria, as determined by 2 reviewers. DATA EXTRACTION: Two reviewers verified extracted data. DATA SYNTHESIS: Four fecal immunochemical tests have superior sensitivity (range, 61% to 91%), and some have similar specificity (97% to 98%) compared with the Hemoccult II fecal occult blood test (Beckman Coulter, Fullerton, California). Tradeoffs between superior sensitivity and reduced specificity occur with high-sensitivity guaiac tests and fecal DNA, with other important uncertainties for fecal DNA. In settings with sufficient quality control, CT colonography is as sensitive as colonoscopy for large adenomas and colorectal cancer. Uncertainties remain for smaller polyps and frequency of colonoscopy referral. We did not find good estimates of community endoscopy accuracy; serious harms occur in 2.8 per 1000 screening colonoscopies and are 10-fold less common with flexible sigmoidoscopy. Limitations: We reviewed the accuracy and harms of screening tests only after a single application. CONCLUSIONS: Fecal tests with better sensitivity and similar specificity are reasonable substitutes for traditional fecal occult blood testing, although modeling may be needed to determine all tradeoffs. CT colonography appears as likely as colonoscopy to detect lesions 10 mm or larger but may be less sensitive for smaller adenomas. Potential radiation-related harms, the effect of extracolonic findings, and the fidelity of test performance of CT colonography in community settings remain uncertain. Emphasis on quality standards is important for implementing any operator-dependent colorectal cancer screening test.
 
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BACKGROUND: Young infants and pregnant women are at increased risk for serious consequences of influenza infection. Inactivated influenza vaccine is recommended for pregnant women but is not licensed for infants younger than 6 months of age. We assessed the clinical effectiveness of inactivated influenza vaccine administered during pregnancy in Bangladesh. METHODS: In this randomized study, we assigned 340 mothers to receive either inactivated influenza vaccine (influenza-vaccine group) or the 23-valent pneumococcal polysaccharide vaccine (control group). Mothers were interviewed weekly to assess illnesses until 24 weeks after birth. Subjects with febrile respiratory illness were assessed clinically, and ill infants were tested for influenza antigens. We estimated the incidence of illness, incidence rate ratios, and vaccine effectiveness. RESULTS: Mothers and infants were observed from August 2004 through December 2005. Among infants of mothers who received influenza vaccine, there were fewer cases of laboratory-confirmed influenza than among infants in the control group (6 cases and 16 cases, respectively), with a vaccine effectiveness of 63% (95% confidence interval [CI], 5 to 85). Respiratory illness with fever occurred in 110 infants in the influenza-vaccine group and 153 infants in the control group, with a vaccine effectiveness of 29% (95% CI, 7 to 46). Among the mothers, there was a reduction in the rate of respiratory illness with fever of 36% (95% CI, 4 to 57). CONCLUSIONS: Inactivated influenza vaccine reduced proven influenza illness by 63% in infants up to 6 months of age and averted approximately a third of all febrile respiratory illnesses in mothers and young infants. Maternal influenza immunization is a strategy with substantial benefits for both mothers and infants. (ClinicalTrials.gov number, NCT00142389.)
 
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BACKGROUND: Some studies have suggested that increased blood pressure has a stronger effect on the risk of cardiovascular disease (CVD) in lean persons than in obese persons, although this is not a universal finding. Given the inconsistency of this result, we tested it using a large population-based cohort data set. METHODS AND RESULTS: Systolic and diastolic blood pressures (BPs) and body mass index were measured in 1 145 758 Swedish men born between 1951 and 1976 who were in young adulthood (median age 18.2 years). During the register-based follow-up, which lasted until the end of 2006, 65 611 new CVD events took place, including 6799 myocardial infarctions and 8827 strokes. Hazard ratios (HRs) per 1-SD increase in systolic and diastolic BP were computed within established body mass index categories (underweight, normal, overweight, or obese) with Cox proportional hazards models. The strongest associations of diastolic BP with CVD (HR 1.18), myocardial infarction (HR 1.22), and stroke (HR 1.13) were observed in the obese category. For systolic BP, the strongest associations were observed in the obese category with CVD (HR 1.16) and stroke (HR 1.29) but in the overweight category with myocardial infarction (HR 1.19). We observed statistically significant interactions (P<0.0001) with body mass index for diastolic BP in relation to CVD and for systolic BP in relation to CVD and stroke. CONCLUSIONS: In contrast to the findings of previous studies, we observed a general increase in the magnitude of the association between blood pressure and subsequent CVD with increasing body mass index. Hypertension should not be regarded as a less serious risk factor in obese than in lean or normal-weight persons.
 
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BACKGROUND: Smoking shortens life expectancy by 7 to 10 years. However, it is unclear whether the enhanced longevity of nonsmokers produces increased disability and decreased quality of life during these extra final years. This study evaluates the long-term effect of smoking in midlife on health-related quality of life (HRQoL) in old age. METHODS: Prospective cohort study with a 26-year follow-up of 1658 white men (born 1919-1934) of similar socioeconomic status who were participating in the Helsinki Businessmen Study. All men were healthy at baseline in 1974, when cardiovascular risk factors and smoking habits were assessed. The participants were reevaluated with the use of mailed questionnaires in 2000; HRQoL was measured with the use of the RAND 36-Item Health Survey (similar to the Medical Outcomes Study Short-Form Health Survey) and related to the baseline smoking status. Total mortality through 2000 was determined from Finnish national registers. RESULTS: Participants who had never smoked (n = 614) lived a mean of 10 years longer than heavy smokers (>20 cigarettes daily; n = 188). Among survivors in 2000 (n = 1131), the never-smokers had the highest (ie, best) scores on all RAND 36-Item Health Survey scales. The differences were greatest between never-smokers and heavy smokers, ranging from 4 points on the scale of social functioning to 14 points on the physical functioning scale. The physical component summary score showed a graded deterioration of HRQoL with an increasing number of cigarettes smoked daily (P = .01). CONCLUSIONS: During the 26-year follow-up of this socioeconomically homogeneous male cohort, HRQoL deteriorated with an increase in daily cigarettes smoked in a dose-dependent manner. Never-smokers lived longer than heavy smokers, and their extra years were of better quality.
 
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OBJECTIVE: To present an overview of the association between depressive symptoms in childhood and adolescence and subsequent overweight in later life. DATA SOURCES: MEDLINE, EMBASE, and Web of Science for all indexed journals from January 1, 1997, to May 30, 2007. STUDY SELECTION: Abstracts of 513 articles were reviewed manually. Studies were excluded if unrelated to depressive symptoms and overweight (n = 460), if they were conducted in an adult population (n = 10) or in a population of all age groups (n = 2), or if they were performed in clinic-based populations of overweight participants. In total, 32 articles were reviewed including 21 cross-sectional and 11 longitudinal reports. Main Exposure Depressive symptoms in childhood and adolescence. Main Outcome Measure Overweight. RESULTS: Four cross-sectional studies that satisfied our quality criteria revealed an association between depressive symptoms and overweight in girls aged 8 to 15 years, reporting different effect sizes including a correlation coefficient of 0.14 and a regression coefficient of 0.27. Four longitudinal studies in accord with our quality criteria suggest that depressive symptoms in childhood or adolescence are associated with a 1.90- to 3.50-fold increased risk of subsequent overweight (95% confidence intervals varying from 1.02 to 5.80, respectively). CONCLUSION: These results support a positive association between depressive symptoms at age 6 to 19 years and overweight in later life, assessed after a period of 1 to 15 years.
 
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The association between alcohol intake and pancreatitis has been examined previously in case-control studies, mostly consisting of men. The significance of beverage type and drinking pattern is unknown. The objective of this study was to assess the association between amount, type, and frequency of alcohol intake and risk of pancreatitis. For this purpose, the authors used data on 17,905 men and women who participated in the Copenhagen City Heart Study in 1976-1978, 1981-1983, 1991-1994, and 2001-2003 in Copenhagen, Denmark. Alcohol intake and covariates were assessed by questionnaire. Information on pancreatitis was obtained from national registers. A high alcohol intake was associated with a higher risk of pancreatitis. Hazard ratios associated with drinking 1-6, 7-13, 14-20, 21-34, 35-48, and >48 drinks/week were 1.1 (95% confidence interval (CI): 0.8, 1.6), 1.2 (95% CI: 0.8, 1.8), 1.3 (95% CI: 0.8, 2.1), 1.3 (95% CI: 0.7, 2.2), 2.6 (95% CI: 1.4, 4.8), and 3.0 (95% CI: 1.6, 5.7), respectively, compared with 0 drinks/week (P(trend) < 0.001). Associations were similar for men and women. Drinking frequency did not seem to be independently associated with pancreatitis.
 
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The relative impact of body mass index (BMI) and exercise capacity on mortality in patients with an intermediate to high likelihood of coronary artery disease (CAD) is not clear. Thus, the effect of BMI and exercise capacity on all-cause mortality in patients referred for stress myocardial perfusion imaging was investigated. The outcome of 2,119 patients undergoing exercise stress myocardial perfusion imaging from 1995 to 1999 was assessed. Patients lacked known CAD, but were at intermediate to high risk. Mortality outcome data were obtained from the Social Security Administration Death Master File. There were 183 deaths during an average follow-up of 8.4 +/- 1.4 years. A Cox proportional hazards model identified age, Bruce protocol exercise time, BMI, male gender, and diabetes mellitus as significant predictors of all-cause mortality. In multivariate analysis, both exercise capacity and BMI correlated inversely with mortality, with higher chi-squared impact related to exercise capacity than BMI. In conclusion, both increased exercise capacity and BMI were associated with lower mortality in patients with an intermediate to high likelihood of CAD after controlling for confounding variables, supporting an inverse impact of BMI on mortality. The origin for this ``obesity paradox`` is unclear.
 
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