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Global maternal mortality associated with SARS-CoV-2 infection: a systematic review and meta-analysis
Get PDFBackground
Pregnant and recently pregnant women infected with SARS-CoV-2 are at increased risk of death and serious complications than those without the infection. The extent of variation in mortality rates in pregnant women with SARS-CoV-2 infection across regions, and the causes of death are not known. We systematically reviewed all available evidence on the variation in mortality rates in pregnant women with SARS-CoV-2 infection across geographical and country income groups, and the reported cause of death.
Methods
We searched major databases (December 2019–January 2023) including Medline, LILACS, BIREME and Embase. We included studies that reported deaths in at least 10 consecutive pregnant or recently pregnant women with confirmed SARS-CoV-2 infection and assessed the studies’ risk of bias. We calculated the summary estimates of any cause of death as proportions with 95% CIs using a multilevel random-effects logistic regression model. Subgroup analyses were performed by geographical region and country income groups. We used International Statistical Classification of Diseases and Related Health Problems-Maternal Mortality to categorise the reported cause of death.
Findings
From 1 326 315 citations, we included 169 studies (319 172 women with confirmed SARS-CoV-2 infection; 4253 women died). The overall rate of unspecified maternal death was 0.87% (95% CI 0.64% to 1.16%). There were significant differences between geographical regions in rates of maternal mortality, with the highest rates in Sub-Saharan Africa (3.48%; 95% CI 0.66% to 16.42%) and Latin America and the Caribbean (3.16%, 95% CI 1.53% to 6.43%). Rates of maternal mortality varied by country income groups, with the highest rates in low-income countries (4.66%, 95% CI 0.75% to 24.07%). Among women with reported cause of death, 98.6% (2,390/2,423) of deaths were attributable to COVID-19.
Interpretation
Rates of deaths in pregnant and recently pregnant women with SARS-CoV-2 infection vary significantly across regions and by country income groups, with the highest burden in Sub-Saharan Africa and low-income countries. COVID-19 is the main reported cause of death.
PROSPERO registration number
CRD42020224120
Pneumococcal vaccination for new residents entering older adult care homes in England: national observational surveillance study
Get PDFBackground
The incidence of invasive pneumococcal disease (IPD) increases rapidly with age. In the UK, adults aged 65 years are eligible for the 23-valent pneumococcal polysaccharide vaccine (PPV23) as part of the national immunisation programme, and a 20-valent pneumococcal conjugate vaccine (PCV20) was recently licensed for adults. Residents of care homes for older adults have a higher risk of IPD and death than the general population. We estimated the potential effect of an additional dose of PPV23 or PCV20 for new residents entering older adult care homes.
Methods
In this observational surveillance study, we used national IPD surveillance and care home resident data from England. Care homes for older adults were defined as residential care and nursing homes registered with the Care Quality Commission for adults aged 65 years and older. IPD in adults aged 65 years and older in England was assessed in the 2022–23 epidemiological year (July 1, 2022, to June 30, 2023) by sex and 5-year age bands using data obtained from UK Health Security Agency national IPD surveillance. We calculated the number needed to vaccinate (NNV) with PPV23 or PCV20 in the population of new care home residents to prevent one vaccine-type IPD case and one death compared with adults aged 65 years who were vaccinated as part of the national immunisation programme in England.
Findings
In 2022–23, there were 2574 IPD cases among 10 629 867 people aged 65 years and older in England. Of these, 603 109 were aged 65 years. Of the 2574 cases, 69·4% (1787 of 2574) were due to PPV23 serotypes and 60·8% (1566 of 2574) were due to PCV20 serotypes. Under the assumption of 36% vaccine effectiveness against PPV23-type IPD and 18% vaccine effectiveness against death, PPV23, when offered to all 603 109 adults aged 65 years in the general population, could prevent 163 (36%) of 452 cases (NNV 3700) and 31 (47%) of 66 PPV23-type IPD associated deaths over 5 years (NNV 19 455). However, vaccinating 121 587 new care home residents with PPV23 could prevent 177 (36%) of 492 lifetime cases (NNV 687) and 111 (48%) of 233 deaths (NNV 1095). In all adults aged 65 years in the general population, PCV20 could prevent 303 (75%) of 404 cases (NNV 1990) and 43 (80%) of 54 PCV20-type IPD deaths (NNV 14 026), assuming 75% vaccine effectiveness against PCV20-type IPD and 18% against death. However, vaccinating 121 587 new care home residents with PCV20 could prevent 317 (75%) of 422 cases (NNV 384) and 157 (80%) of 197 deaths (NNV 774).
Interpretation
Pneumococcal vaccination for new care home residents could prevent substantially more cases and deaths per dose and would require only 20% more doses than the current national PPV23 programme for adults aged 65 years. PCV20 is likely to have a greater impact against IPD and death than PPV23.
Funding
None
ECG characteristics as indicators of the aetiology of pulseless electrical activity: a systematic review
No full textIntroduction: The incidence of pulseless electrical activity (PEA) as a presenting rhythm in out-of-hospital cardiac arrest is rising in comparison with other rhythms. Prompt recognition of the cause of PEA can improve outcomes. The assessment of electrocardiogram (ECG) characteristics
during resuscitation has been suggested as a source of diagnostic information for clinicians. The aim of this systematic review was to identify literature evaluating the use of ECG characteristics as indicators of the aetiology of PEA and to consider how their findings may be utilised in clinical
practice.Methods: Case series, observational studies, randomised controlled trials and empirical research investigating the ECG characteristics of adult patients and reporting the aetiology of PEA were searched for via a systematic literature search of the MEDLINE, CINAHL Plus and
EMBASE databases. Searches for grey literature were performed, as well as reference screening. A risk-of-bias assessment was undertaken for each included study.Results: A total of four articles were selected for final inclusion. One study reported a statistically significant correlation
between the presence of wide QRS complexes and hyperkalaemia. No further associations between ECG characteristics and the aetiology of cardiac arrest were reported. Three studies were found to be at moderate risk of bias due to incomplete inclusion of patients. Studies often assessed groups
of aetiologies, rather than specific causes. Consequently, this limits their application in clinical practice.Conclusion: ECG characteristics should not be used in isolation as an indicator of the aetiology of cardiac arrest in patients with PEA. The included studies often employed
broad categorisations of aetiologies, limiting their ability to identify specific characteristics associated with individual causes. Future research should include analysis of specific aetiologies and the evaluation of ECG characteristics to augment other diagnostic tools
Limited incremental value of growth differentiation factor 15 in the initial evaluation of low and intermediate risk acute chest pain patients
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Expression of the cytokine growth differentiation factor 15 (GDF-15) is up-regulated in conditions of tissue injury and stress. We evaluated if GDF-15 predicts obstructive coronary artery disease (CAD) or need for revascularization within 30 days and 12 months in low/intermediate risk patients with acute chest pain.
Materials and Methods
We included 537 hospitalized patients who had high-sensitivity troponin T (hs-cTnT) < 99th percentile and underwent coronary CT angiography (CCTA). Odds ratios (ORs) and 95 % confidence intervals (CI) were calculated by logistic regression analyses and are reported per standard deviation increment of GDF-15 (log-transformed).
Results
The median (25th-75th percentile) age was 56 (49–65) years, 217 (40.4 %) were women, 83 (15.5 %) had obstructive CAD at CCTA. In total 49 (9.1 %) patients underwent revascularization within 30 days and 52 (9.7 %) within 12 months. In age and sex adjusted analysis GDF-15 was a significant predictor with ORs (95 % CI) of 1.35 (1.05–1.73), 1.39 (1.06–1.83) and 1.41 (1.07–1.84) for obstructive CAD, revascularization within 30 days and 12 months, respectively. However, after adjustment for clinical covariables, the ORs of GDF-15 were no longer statistically significant for either outcome (P ≥ 0.07). Adding hs-cTnT levels alone to the age and sex adjusted model also rendered the ORs of GDF-15 non-significant (P ≥ 0.31).
Conclusions
In patients with acute chest pain but without acute myocardial infarction, GDF-15 did not substantially improve the identification of obstructive CAD or need for revascularization within 30 days and 12 months. Our findings question the clinical usefulness of GDF-15 for prognostication of low-risk patients with acute chest pain
The Role of Cardiovascular Magnetic Resonance Imaging in Athletic Individuals-A Narrative Review
Get PDFCardiovascular magnetic resonance imaging (MRI) is an advanced cardiac imaging modality that is often required when evaluating athletic individuals. Unrestricted imaging planes, excellent spatial resolution, and a lack of ionising radiation are some of the benefits of this modality. Cardiac MRI has been established as the gold standard imaging modality for morphological assessment, volumetric analysis, and tissue characterisation. Cardiac MRI without any doubt is an excellent diagnostic tool when evaluating athletes with symptoms or those individuals exhibiting equivocal findings at screening. It is also useful for athletes who fall within the grey zone and is especially important among athletes with a suspected or confirmed diagnosis. Cardiac MRI plays a strategic role when adopting a shared decision-making model in athletes with heart disease, tailoring and personalising medical care to the condition and the athlete’s wishes. The aim of this review is to provide a comprehensive yet practical overview of the role of cardiac MRI when evaluating athletes in clinic
Users’ Perceptions of Access to and Quality of Public Health Services in Brazil: A Cross-Sectional Study in Metropolitan Rio de Janeiro, including pharmaceutical services
Get PDFBackground: This study evaluates one of the five regions of the state of Rio de Janeiro, Brazil, as part of a broader research project examining users’ perceptions of the Unified Health System (SUS), which has already generated publications in previous phases. The aim was to assess users’ perceptions of the SUS regarding access to and the quality of public health services, including pharmaceutical services, in the Metropolitan Region of Rio de Janeiro State. Method: A cross-sectional study was conducted between January and August 2024 with 200 participants, using a 66-item survey addressing access to and the quality of SUS services, appointment scheduling, medication acquisition, and the pharmacist’s role. Associations between variables were investigated using the Pearson Chi-Square Test in R software. Results: Frequent SUS users rated access as very good/good (p = 0.002) and overall quality as very good/good (p = 0.045). Reported challenges included the need for improved infrastructure (48.5%), better professional qualifications (30.6%), and easier access to medicines (16.8%). Higher ratings were given by those who used the SUS more frequently, and, in general, there was a tendency for participants with lower socioeconomic conditions to provide more favorable assessments of access to public health services (p = 0.024). Conclusion: A universal health system should cover diverse regions with unique needs. However, 49.4% of participants stated they never received information on how to store their medicines, and 42.3% reported never encountering a pharmacist in public pharmacies. Further ongoing studies assessing user perceptions are essential to ensure users play a central role in health decision-making, contributing to the system’s strengthening and improvement
Evaluating the Accuracy and Reliability of Splenic Artery Aneurysm Assessment on Computed Tomography Imaging
Get PDFBACKGROUND: Splenic artery aneurysms (SAAs) are the third most common abdominal arterial aneurysm. Several radiological features have been associated with their growth rate and rupture risk. We aim to evaluate the accuracy and reliability in assessing these features on computed tomography scans. METHODS: Radiological reports were searched for scans positive for SAA between 2012 and 2021 inclusive. These scans were assessed with our novel radiological proforma by 2 radiologists to determine those criteria which were reliably reported. A nonexpert was then compared against this baseline to assess the reliability of SAA assessment by nonradiologists. Pearson and Spearman rank correlation coefficients and Cohen Kappa statistics was used to assess agreement. RESULTS: A cohort of 170 scans was assessed. A high degree of agreement (correlation coefficient r = 0.89-0.91) was achieved by radiologists for SAA diameter measurement. A high level of agreement was also achieved for calcification (Kappa = 0.827) and previous intervention (1.0), moderate agreement for presence of SAA (0.563), calcification percentage (0.563), morphology (0.446), and presence of thrombus (0.516). Rupture and pseudoaneurysm morphology demonstrated poor agreement (Kappa <0.01) but were rare events limiting interpretation. A nonexpert could achieve comparable diameter measurements (P < 0.05) but had consistently lower kappa agreements for all aneurysm characteristics compared to radiologists. CONCLUSION: Aneurysm diameter, calcification, and previous intervention were the only features reported with high agreement between radiologists. Other SAA characteristics only achieved moderate or poor agreement and so should be used with caution in research and clinical settings
Vaccine-preventable diseases in migrants in Europe: a systematic review
Get PDFBackground:
Migrants in Europe often face barriers to vaccination, increasing their vulnerability to vaccine-preventable diseases (VPDs). Despite policies promoting catch-up immunisation on arrival, data on VPD burden and outcomes among migrants remain limited. This systematic review synthesises evidence on the prevalence, incidence, mortality, and outcomes of VPDs in migrants across EU/EEA countries, UK, and Switzerland.
Methods:
We searched Medline, Embase, Global Health, and grey literature sources (including websites of national public health organisations and agencies) for primary studies and reports on VPD cases among migrants (foreign-born individuals) in 32 European countries, published between January 2010 and April 2024. Data on demographics, VPD type, vaccination status, and outcomes were extracted. We focused on diphtheria, measles, mumps, pertussis, rubella, and tetanus. Study quality was assessed using Joanna Briggs Institute tools.
Results:
Fifty-seven studies met inclusion criteria, reporting 1950 VPD cases in migrants across 16 countries (2010–2024). Most studies were in Germany (n = 12), Spain (n = 11), Switzerland (n = 8), Greece (n = 6), and the UK (n = 7). Reported cases included: measles (n = 992; 50.8 %), diphtheria (n = 546; 28.0 %), pertussis (n = 267; 13.7 %), and mumps (n = 137; 7.0 %). No cases of rubella or tetanus were reported. Migrants affected mainly included asylum seekers (n = 23 studies), refugees (n = 6), labour migrants (n = 2). Six studies from Greece, Germany, and Spain accounted for 1942 cases (99.6 %). Over half of diphtheria cases (n = 307; 55.4 %) occurred in reception centres. Diphtheria primarily affected adolescents and adults (n = 10 studies), while measles cases were mostly in children. Migrants from the Eastern Mediterranean and Africa were disproportionately affected by diphtheria. Non-EU/EEA European migrants (WHO EUR), mainly from Bosnia and Herzegovina and Serbia, accounted for most measles cases (87 %), and non-European migrants were from Somalia (n = 112), Afghanistan (n = 94), Eritrea (n = 76), and Syria (n = 64). Vaccination status was unknown or unreported in over 60 % of cases. Five VPD related deaths were reported of which 4/5 were due to measles.
Conclusion:
Migrants are at increased risk of VPDs due to gaps in vaccination. Strengthening catch-up vaccination, particularly in adolescents and adults, and improving data collection are essential next steps
Identification of gestational diabetes mellitus in European electronic healthcare databases: insights from the ConcePTION project
Get PDFObjective
To develop and compare algorithms for identifying gestational diabetes mellitus (GDM) across European electronic healthcare databases and evaluate their impact on the estimated prevalence.
Design
Multi-national cohort study using routinely collected electronic healthcare data
Setting
National and regional databases in five European countries (Norway, Finland, Italy, Spain and France), in primary and/or secondary care.
Participants
Pregnancy cohorts resulting in stillbirths or live births between 2009 and 2020, comprising 602 897 pregnancies in Norway, 507 904 in Finland, 374 009 in Italy, 193 495 in Spain and 116 762 in France.
Primary and secondary outcomes
The primary outcome was the prevalence of GDM identified using six algorithms: (1) Only diagnosis; (2) Diagnosis or prescription; (3) Two diagnoses or prescriptions (2DxRx); (4) Diagnosis including unspecified diabetes in pregnancy or prescription (DxRx broad); (5) Diagnosis excluding pre-existing diabetes in pregnancy or prescription; (6) Registration of GDM in a birth registry (BR).
Results
The strictest algorithm (2DxRx) resulted in the lowest GDM prevalence, while the broadest (DxRx broad) resulted in the highest, except in France where it was BR. In the Nordic countries, GDM prevalence varied only slightly by algorithm; greater variations were observed in other countries. The prevalence ranged from 3.5% (95% CI: 3.5% to 3.5%) to 4.6% (95% CI: 4.5% to 4.7%) in Norway; 12.1% (95% CI: 12.0% to 12.2%) to 15.8% (95% CI: 15.7% to 15.9%) in Finland, where prevalence was much higher than elsewhere. The prevalence ranged from 1.3% (95% CI: 1.3% to 1.3%) to 5.4% (95% CI: 5.3% to 5.5%) in Italy; 1.6% (95% CI: 1.5% to 1.7%) to 6.2% (95% CI: 6.1% to 6.3%) in Spain; and 1.7% (95% CI: 1.6% to 1.8%) to 5.8% (95% CI: 5.7% to 5.9%) in France.
Conclusions
In this multinational study, GDM prevalence ranged from 1.3% to 15.8% depending on the algorithm and database. Nordic countries showed smaller differences in prevalence between algorithms, while the other countries showed larger variations, likely due to differences in coding practices, healthcare systems and database coverage
Uncovering drug targets for cluster headache through proteome-wide Mendelian randomization analysis
Get PDFBackground
Cluster headache (CH) is a highly disabling primary headache disorder with a complex underlying mechanism. However, there are currently no effective targeted therapeutic drugs available. Existing medications often have limited efficacy and numerous side effects, which frequently fail to meet clinical needs. This study aims to identify potential new therapeutic targets for CH through proteome-wide mendelian randomization (PWMR).
Methods
We used PWMR to estimate the causal effects of plasma proteins on CH. This analysis integrated plasma protein quantitative trait loci (pQTL) data with genome-wide association study (GWAS) results of CH phenotypes. In addition, we conducted various sensitivity analyses, enrichment analyses, phenome-wide MR assessments, protein–protein interaction network construction, and mediation MR analyses to further validate the drug potential of the identified protein targets.
Results
We identified 11 protein targets for CH (p < 2.41 × 10–5), with high-priority candidates exhibiting minimal side effects. Phenome-wide MR revealed novel targets—PXDNL, CCN4, PKD1, LGALS9, and MRC1—that show no significant disease-related adverse effects and interact with established preventive CH drug targets. Notably, PXDNL interacts with both acute and preventive CH drug targets. Furthermore, the causal effect of plasma proteins on CH is partially mediated by cortical surface area, with mediation proportions ranging from 3.2% to 10.0%.
Conclusions
We identified a set of potential protein targets for CH, characterized by rare side effects and a strong association with the biological mechanisms underlying the disorder. These findings offer valuable insights for the development of targeted drug therapies in the treatment of CH
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