Annals of Internal Medicine最新文献

Clinical impact ratings: GIM/FP/GP: [Formula: see text] Cardiology: [Formula: see text].

Clinical impact ratings: GIM/FP/GP: [Formula: see text] Infectious Disease: [Formula: see text] Pulmonology: [Formula: see text].

Clinical impact ratings: Emergency Med: [Formula: see text] Neurology: [Formula: see text].

Background: Anemia affects up to 50% of pregnancies. The relation between early pregnancy maternal hemoglobin concentration and important perinatal outcomes in high-income countries is largely unknown.

Objective: To assess early pregnancy hemoglobin concentration and associated severe neonatal morbidity and mortality (SNM-M) in a high-income setting.

Design: Population-based, retrospective cohort study.

Setting: Ontario, Canada, where health care is publicly funded.

Participants: Women aged 18 to 50 years with a singleton birth between 2007 and 2023 and hemoglobin measurement at 2 to 12 weeks' gestation.

Measurements: The nonlinear relation between early pregnancy hemoglobin concentration and SNM-M was analyzed in 1-g/L increments using restricted cubic splines, with 125 g/L as the referent. The primary outcome was a validated composite measure of SNM-M (major neonatal conditions and critical interventions) up to 27 days after birth. Relative risks (RRs) were adjusted (aRR) for maternal demographic characteristics and chronic conditions.

Results: A total of 1 100 341 births were included. A U-shaped relation was observed between early pregnancy hemoglobin concentration and SNM-M. For example, relative to a hemoglobin value of 125 g/L and a corresponding SNM-M rate of 6.7%, the aRR for SNM-M was 1.08 (95% CI, 1.04 to 1.11) at a hemoglobin concentration of 105 g/L and 1.17 (CI, 1.10 to 1.25) at 90 g/L. The aRR for SNM-M was 1.05 (CI, 1.03 to 1.07) at a hemoglobin concentration of 135 g/L and 1.20 (CI, 1.16 to 1.24) at 150 g/L.

Limitation: Iron replacement status before and during pregnancy was unknown, and residual confounding may influence observed associations.

Conclusion: Maternal anemia and relative erythrocytosis were each associated with neonatal morbidity and mortality in a high-income setting. Randomized clinical trials should evaluate the effect of iron therapy on maternal and perinatal outcomes by degree of hemoglobin correction.

Primary funding source: University of Toronto Alexandra Yeo Hematology Grant.

Clinical impact ratings: GIM/FP/GP: [Formula: see text].

Background: Widespread vaccination for human papillomavirus (HPV) alters the landscape of cervical cancer (CC) risk, requiring adaptations to the CC screening program.

Objective: To assess the cost-effectiveness and harm-benefit tradeoffs of adapting CC screening strategies on the basis of age at HPV vaccination.

Design: Individual-based mathematical modeling study.

Data sources: Published data.

Target population: Hypothetical cohorts of women vaccinated in 7 different age groups (12, 13 to 15, 16 to 18, 19 to 21, 22 to 24, 25 to 27, and 28 to 30 years) with either bivalent or nonavalent vaccines in Norway.

Time horizon: Lifetime.

Perspective: Extended health care sector (that is, including patient time and travel costs).

Intervention: HPV-based screening strategies that varied screening start age, interval, and number of lifetime screening tests.

Outcome measures: Incremental cost-effectiveness ratios, defined as the additional cost per quality-adjusted life-year (QALY) gained. "Preferred" (that is, cost-effective) screening for each age group was identified using a cost-effectiveness threshold of $55 000 per QALY. Harm-benefit tradeoffs were quantified as the ratio of colposcopy referrals to CC cases averted.

Results of base-case analysis: For all vaccination age groups and both vaccines, less frequent screening with longer intervals between screening than the 5-year interval currently recommended was consistently preferred at the threshold of $55 000 per QALY, but the preferred strategy varied by age at vaccination. For women vaccinated between ages 12 and 24 years, preferred strategies involved screening every 15 to 25 years, resulting in screening 2 to 3 times per lifetime.

Results of sensitivity analysis: Less frequent screening remained a preferred strategy under imperfect screening adherence and in scenarios that excluded bivalent vaccine cross-protection.

Limitation: The analysis did not address screening for unvaccinated women, who may benefit from herd immunity.

Conclusion: A high-value screening program likely involves less frequent screening for women who were vaccinated against HPV by age 30 years. Strategies could be tailored on the basis of age at vaccination and type of HPV vaccine.

Primary funding source: Norwegian Cancer Society and National Cancer Institute.