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of toxemia, twice during difficult versions in primiparous patients, and three times of unknown causes. Diagnosis of cerebral hemorrhage was made eight times : four times clinically and four times by autopsy observations. Of these eight cases, five occurred among patients in whom the second stage was prolonged over

The burden of disease associated with the obesity epidemic shortens lives, and prevalence is accelerating. As with other chronic diseases, improved outcomes are associated with effective self-management of obesity across the life span. The disease of obesity, then, fits squarely within the disease management and chronic care models. This article reviews selected interventions, described in peer-reviewed literature, designed to achieve significant weight loss for individuals identified as overweight or obese. The study objective is to provide an overview of the full range of methods and models for weight loss, including some available without medical supervision. The intended audience includes individuals and organizations with an expressed interest in disease management and the chronic care models. Our review identified promising lines of investigation for future research that span diverse medical disciplines applied to obesity. The quality of the studies included in our review was uneven, and compromises the current evidence for effectiveness and efficacy. Generally, our results showed that combination approaches-surgical or pharmacologic, combined with a behavioral intervention-were most likely to be effective.

A n estimated 7.9 million persons in the United States have experienced acute myocardial infarction (MI) and 5.2 million have been diagnosed with heart failure (HF).1 MI and HF result in elevated morbidity and mortality risks and substantial economic burden.1,2 HF accounts for an estimated 1 million hospital stays annually, and $33.2 billion in direct and indirect costs to society annually. Direct and indirect costs to society for coronary heart disease, of which MI is a major contributor, is estimated at $162 billion annually. 1Up to 74% of patients hospitalized for MI will be readmitted for MI again or another cardiovascular diagnosis within 3 years.3 Among patients hospitalized for HF, 30% to 40% will be readmitted within 6 months.4 A large percent of these readmissions may be preventable if established guidelines for care, including use of medications, were followed.American College of Cardiology ⁄ American Heart Association (ACC ⁄ AHA) guidelines emphasize angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) therapy following acute MI or development of HF as the cornerstone of treatment complemented by aldosterone agonists and b-blockers.5 The guidelines are supported by clinical trials demonstrating the efficacy of ACEIs in reducing mortality and morbidity in patients with HF and MI dating back some 20 years [6][7][8][9] ; and clinical trials demonstrating reduced mortality and morbidity rates in cohorts of MI or HF patients treated with ARB therapies. [10][11][12] In addition, studies of patient adherence to evidence-based pharmacotherapies in MI and HF patients have consistently found a strong association between higher rates of adherence and better outcomes. A population-based, longitudinal study of 31,455 elderly MI survivors between 1999 and 2003 in Ontario found that adherence is positively correlated with long-term survival. 13 An analysis of the effect of b-blockers, aspirin, lipid-lowering agents, and ACEI therapy on survival in a large population treated for MI, HF, and other cardiovascular diseases also found that rates of patient adherence to evidencebased pharmacotherapies were strongly associated with rates of survival at 5 years post discharge.14 A large population-based study in Denmark of HF patients prescribed ACEI, ARB, b-blockers or statins post-discharge reported higher mortality among nonpersistent patients. 15Less is known about the effects of ACEI or ARB therapies on the risk of hospitalization for MI and HF patients, a common and costly event for this patient population. The effectiveness of ACEI or ARB therapies in reducing American College of Cardiology ⁄ American Heart Association guidelines recommend angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) therapy following acute myocardial infarction (MI) or development of heart failure (HF). This study estimated the effects of initiating these therapies after hospitalization for MI or HF on subsequent 1-year rehospitalization rates for MI