JAMA Network Open最新文献

Importance: Supervised pelvic floor muscle training (PFMT) has been recommended as the first-line treatment for women with stress urinary incontinence (SUI), but more evidence on whether adjunctive methods would provide additional benefits is needed.

Objective: To compare the efficacy of PFMT with or without a home-based pressure-mediated biofeedback (BF) device.

Design, setting, and participants: This multicenter assessor-blinded randomized clinical trial was conducted in the obstetric clinics of 5 participating tertiary hospitals in China. Participants included eligible women with new-onset postpartum SUI who were enrolled from March 28, 2022, to October 13, 2023.

Intervention: All participants received 3 months of supervised PFMT and were randomized to either the intervention (PFMT with a home-based pressure-mediated BF device) or the control group (home-based PFMT).

Main outcome and measures: The primary outcome was the severity of urinary incontinence evaluated by the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form after 3 months of supervised PFMT. The secondary outcomes included the cure and improvement rates, PFM strength, quality of life, self-efficacy, and adherence.

Results: A total of 452 participants (median age, 34 [IQR, 31-36] years; median body mass index [calculated as the weight in kilograms divided by the height in square meters], 23.71 [IQR, 21.37-25.97]; median time since delivery, 50 [IQR, 43-61] days) were included in the analysis, with 223 in the intervention group and 229 in the control group. Compared with the control group, the intervention group achieved a significantly greater reduction in incontinence severity (median, 3.00 [IQR, 1.00-6.00] vs 2.00 [IQR, 0-4.00] points; z = -3.05; P = .002), significantly increased cure rate (45 of 223 [20.2%] vs 20 of 229 [8.7%]; z = 12.02; P = .001) and improvement (132 of 223 [59.2%] vs 102 of 229 [44.5%]; z = 9.71; P = .002), significantly greater pelvic floor muscle strength (median, 26.00 [IQR, 17.00-38.00] vs 21.00 [IQR, 13.50-33.50] cm H2O; z = -2.28; P = .02), and a significantly greater correlation between subjective and objective adherence (r = 0.825 vs r = 0.627).

Conclusion and relevance: In this randomized clinical trial, the efficacy of pressure-mediated BF combined with PFMT was superior to that of PFMT alone. These findings support the use of pressure-mediated BF devices for improving treatment outcomes for patients with SUI.

Trial registration: ClinicalTrials.gov Identifier: NCT05115864.

Importance: A negative association between neonatal mortality and hospital delivery has been found in some low- and lower-middle-income countries but not in rural settings characterized by poor quality of maternal and child health care.

Objective: To examine the association between neonatal mortality and hospital delivery in China across urban and rural regions, regional disparities, and varying levels of economic development.

Design, setting, and participants: This retrospective cohort study used county-level data from 2008 to 2020 from the National Maternal & Child Health Statistics across mainland China. Statistical analysis was conducted from March to December 2023.

Exposures: Since 2008, China has strategically leveraged hospital deliveries with national subsidies to diminish neonatal mortality, particularly in rural areas.

Main outcomes and measures: Neonatal mortality and hospital delivery rates were calculated, and their association was estimated using multivariable fixed-effects linear models of county-level cohort data to adjust for time-invariant differences across counties and controls for gross domestic product (GDP) per capita, women's years of education, hospital beds, and health workers.

Results: The analysis included data from 2930 counties, with 198.7 million live births across 36 255 county-year records between 2008 and 2020. The mean (SD) neonatal mortality rate per 1000 live births decreased in rural areas from 12.3 (7.5) in 2008 to 3.9 (2.7) in 2020 and decreased in urban areas from 5.0 (3.1) in 2008 to 2.0 (1.3) in 2020. Hospital delivery rates increased in rural areas from a mean (SD) of 93.4% (11.8%) in 2008 to 99.9% (0.6%) in 2020 and increased in urban areas from 97.7% (6.1%) in 2008 to 100.0% (0.1%) in 2020. In rural areas, an increase of 10 percentage points in hospital deliveries was associated with a neonatal mortality rate of -1.4 (95% CI, -1.9 to -1.0; P < .001) per 1000 live births, whereas this negative association was not observed in urban areas. When the analysis was stratified by regions and incomes, the negative association became considerably stronger in the western and central regions of China, as well as in counties with lower GDP per capita.

Conclusions and relevance: This cohort study of more than 2900 counties in China suggests that an increase in hospital deliveries was associated with reduced neonatal mortality in rural and economically underdeveloped areas in China. To further reduce neonatal mortality and improve newborn health, it is imperative to increase the accessibility of hospital delivery services.

Importance: Traditional approaches to practice guidelines frequently result in dissociation between strength of recommendation and quality of evidence.

Objective: To create a clinical guideline for the diagnosis and management of urinary tract infections that addresses the gap between the evidence and recommendation strength.

Evidence review: This consensus statement and systematic review applied an approach previously established by the WikiGuidelines Group to construct collaborative clinical guidelines. In May 2023, new and existing members were solicited for questions on urinary tract infection prevention, diagnosis, and management. For each topic, literature searches were conducted up until early 2024 in any language. Evidence was reported according to the WikiGuidelines charter: clear recommendations were established only when reproducible, prospective, controlled studies provided hypothesis-confirming evidence. In the absence of such data, clinical reviews were developed discussing the available literature and associated risks and benefits of various approaches.

Findings: A total of 54 members representing 12 countries reviewed 914 articles and submitted information relevant to 5 sections: prophylaxis and prevention (7 questions), diagnosis and diagnostic stewardship (7 questions), empirical treatment (3 questions), definitive treatment and antimicrobial stewardship (10 questions), and special populations and genitourinary syndromes (10 questions). Of 37 unique questions, a clear recommendation could be provided for 6 questions. In 3 of the remaining questions, a clear recommendation could only be provided for certain aspects of the question. Clinical reviews were generated for the remaining questions and aspects of questions not meeting criteria for a clear recommendation.

Conclusions and relevance: In this consensus statement that applied the WikiGuidelines method for clinical guideline development, the majority of topics relating to prevention, diagnosis, and treatment of urinary tract infections lack high-quality prospective data and clear recommendations could not be made. Randomized clinical trials are underway to address some of these gaps; however further research is of utmost importance to inform true evidence-based, rather than eminence-based practice.

Importance: Postpartum depression (PPD) poses significant risks to maternal and child health. Understanding temporal trends is crucial for evaluating prevalence and identifying populations at risk.

Objective: To evaluate recent trends in PPD and assess how these trends are associated with race, ethnicity, and prepregnancy body mass index (BMI).

Design, setting, and participants: A serial, cross-sectional analysis using data from the Kaiser Permanente Southern California (KPSC) electronic health records (EHRs), with live and stillbirths at 20 or more weeks of gestation who were KPSC members at the time of delivery between 2010 and 2021. Data were analyzed from July 2022 to August 2023.

Exposures: Self-reported race, ethnicity, and recorded prepregnancy BMI.

Main outcome measures: PPD cases were identified using validated diagnostic codes and prescription records within 12 months postpartum in the KPSC EHRs. Patients with an Edinburgh Postnatal Depression Scale score of 10 or more within 6 months postpartum were further evaluated by a mental health specialist for formal PPD diagnosis.

Results: In this study of 442 308 pregnancies, the median (IQR) maternal age at delivery was 31 (27-34) years. The cohort was racially and ethnically diverse, with 62 860 individuals (14.2%) identifying as Asian/Pacific Islander, 231 837 (52.4%) as Hispanic, 33 207 (7.5%) as non-Hispanic Black, 108 201 (24.5%) as non-Hispanic White, 5903 (1.3%) as multiple or other, and 300 (0.1%) unknown. PPD prevalence doubled over the study period, increasing from 9.4% in 2010 to 19.0% in 2021. The largest increases were observed among Asian and Pacific Islander participants (280% increase) and non-Hispanic Black participants (140% increase). PPD rates increased across all BMI categories, particularly among individuals with obesity (class I) and morbid obesity (class II/III).

Conclusions and relevance: In this cross-sectional study, PPD diagnosis increased significantly across all racial and ethnic groups and BMI categories over the past decade. While rising PPD may reflect improved screening and diagnosis practices, the persistently high rates highlight the need to develop and implement interventions to prevent the condition while expanding efforts to mitigate the impact of PPD on maternal and child health.