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Prediction of hypertension and diabetes in twin pregnancy using machine learning model based on characteristics at first prenatal visit: national registry study
Get PDFObjective
To develop a prediction model for hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM) in twin pregnancy using characteristics obtained at the first prenatal visit.
Methods
This was a cross-sectional study using national live-birth data in the USA between 2016 and 2021. The association of all prenatal candidate variables with HDP and GDM was tested on univariable and multivariable logistic regression analyses. Prediction models were built with generalized linear models using the logit link function and classification and regression tree (XGboost) machine learning algorithm. Performance was assessed with repeated 2-fold cross-validation and the area under the receiver-operating-characteristics curve (AUC) was calculated. A P value < 0.001 was considered statistically significant.
Results
A total of 707 198 twin pregnancies were included in the HDP analysis and 723 882 twin pregnancies were included in the GDM analysis. The incidence of HDP and GDM increased significantly from 12.6% and 8.1%, respectively, in 2016 to 16.0% and 10.7%, respectively, in 2021. Factors associated with increased odds of HDP in twin pregnancy were maternal age < 20 years or ≥ 35 years, infertility treatment, prepregnancy diabetes mellitus, non-Hispanic Black race, overweight prepregnancy BMI, prepregnancy obesity and Medicaid as the payment source for delivery (P < 0.001 for all). Obesity Class II and III more than doubled the odds of HDP. Factors associated with increased odds of GDM in twin pregnancy were maternal age ≤ 24 years or ≥ 30 years, infertility treatment, prepregnancy hypertension, non-Hispanic Asian race, maternal birthplace outside the USA and prepregnancy obesity (P < 0.001 for all). Maternal age ≥ 30 years, non-Hispanic Asian race and obesity Class I, II and III more than doubled the odds of GDM. For both HDP and GDM, the performances of the machine learning model and logistic regression model were mostly similar, with negligible differences in the performance domains tested. The mean ± SD AUCs of the final machine learning models for HDP and GDM were 0.620 ± 0.001 and 0.671 ± 0.001, respectively.
Conclusions
The incidence of HDP and GDM in twin pregnancies in the USA is increasing. The predictive accuracy of the machine learning models for HDP and GDM in twin pregnancies was similar to that of the logistic regression models. The models for HDP and GDM had modest predictive performance, were well calibrated and did not have poor fit
Early outpatient treatment of SARS-COV-2 infection in non-hospitalised high-risk paediatric patients in London, UK.
Get PDFThe prevalence of, and risk factors for distal femoral cortical irregularity in the adolescent population
Get PDFIntroduction
There is uncertainty around the pathogenesis and prevalence of distal femoral cortical irregularities (DFCI). We aimed to assess the prevalence of DFCI in a cohort of adolescents that underwent MRI and identify and assess associated risk factors.
Methods
A historical cohort study of adolescents (age 10 - <20 years) undergoing MRI scans was conducted. Data was collected for a period of five years using the Picture Archive and Communication System database at a large tertiary hospital. Data collected included sex, age, mechanism of injury and other pathology present in the original MRI report. Binary logistic regression was used to investigate potential risk factors for DFCI.
Results
897 scans (mean age, 15.3 (SD 2.59) years; 499 (55.6 %) male) were analysed. Prevalence of DFCI among adolescents who had a MRI scan was 9.1 % (95 % CI: 7.3 %–11.2 %). Patients that had experienced DFCI were younger than those that had not (mean age 14.5 vs 15.3 years, P = 0.002). The mechanism of injury differed between patient groups (P = 0.015); Patients with DFCI were more likely to have had a patella instability/dislocation (22.8 % vs 16.1 %), and less likely to have had a pivotal knee injury (12.7 % vs 29.0 %). When compared to patients aged 10–13 years, older children had reduced odds of a DFCI: 13–16 years had an adjusted odds ratio (aOR) of 0.79 (95 % CI: 0.45 to 1.39); 16–20 years (aOR = 0.36; 95 % CI: 0.18 to 0.71). Males had reduced odds of a DFCI (aOR = 0.38; 95 % CI: 0.22 to 0.66).
Conclusions
Female sex and younger age were risk factors for development of DFCI. There was no statistically significant association between mechanism of injury and developing a DFCI. Further research is required to establish its prevalence in those who are asymptomatic and why younger adolescent females are more likely to experience DFCI
Evolution of Spinal Cord Swelling in Acute Traumatic Spinal Cord Injury
Get PDFWe hypothesized that the Monro–Kellie doctrine, a key principle in traumatic brain injury (TBI), also applies in traumatic spinal cord injury (TSCI). By analyzing 9986 h of intraspinal pressure (ISP) monitoring data from 79 TSCI patients, we show that concepts developed to quantify compensatory reserve in TBI may be analogously defined in TSCI, termed ISP pulse amplitude (sAMP), spinal compensatory reserve index (sRAP), and ISP waveform shape. As ISP increases beyond 15 mmHg, compensatory reserve becomes impaired (sAMP rises and sRAP becomes positive). As ISP increases beyond 20 mmHg, the morphology of the ISP waveform changes from three peaks (P1, P2, P3) with P1 dominant, to three peaks with P2 dominant, to a rounded signal. Key differences in TSCI, compared with TBI, are no plateau ISP waves, and no critical ISP beyond which sAMP decreases and sRAP becomes negative. Four factors were associated with increased spinal cord swelling or reduced spinal cord compliance: thoracic level of injury, no laminectomy, delayed surgery, and more severe injury. We also hypothesized that, as in TBI, the spinal cord maximally swells a few days after injury. Serial ultrasound scans of the injured spinal cords in 9 patients and plots of change from baseline in ISP, sAMP, and sRAP versus time in 79 patients revealed delayed maximal cord swelling within 5 days of surgery. We conclude that the spinal Monro–Kellie concept allows the spinal compensatory reserve to be quantified. Our data show that spinal compensatory reserve becomes exhausted as ISP increases above 15–20 mmHg and that there is delayed cord swelling after injury, which implies that adequate cord decompression confirmed during surgery by ultrasound may not persist postoperatively
Myocardial Ischaemic Syndromes: Shifting from a Coronary-Centric to a Substrate-Based Nomenclature is More Accurate and Inclusive
Get PDFThis article highlights the rationale for a more accurate and inclusive classification that does not focus solely on epicardial coronary lesions as the causa sine qua non for angina and myocardial ischaemia in all patients but rather represents a more comprehensive classification encompassing both obstructive and non-obstructive causes. Ischaemia may be ‘silent’ clinically or electrocardiographically and is observed in both acute and non-acute settings, as seen in patients with diabetes and other conditions associated with microvascular dysfunction. By pivoting away from the more restrictive and overly simplistic ‘vessel-based’ classification that disproportionately focuses on obstructed epicardial arteries to a ‘substrate-based’ nomenclature inclusive of both obstructive and non-obstructive causes, ‘myocardial ischaemic syndromes’ will better align and unify a patient-centric approach by harmonising the full spectrum of pathophysiologic causes
Auditory agnosia for environmental sounds in Alzheimer’s disease: Effects on daily life
Get PDFBackground
Auditory agnosia for environmental sounds is a type of agnosia attributed to central auditory dysfunction. It is common in Alzheimer’s disease, and is associated with peripheral hearing loss, although independent of it, and presumed independent of language deficits. The effects of this type of agnosia on daily life in Alzheimer’s disease are unknown.
Objective
We aimed to assess the impact of auditory agnosia for environmental sounds in people with Alzheimer’s disease while also exploring the role of unrecognized hearing loss.
Methods
We tested 34 home-dwelling people with Alzheimer’s disease and a mean MMSE of 21.9 with the aid of a sound naming and recognition test, the tailor-made EESAA (Experiencing Environmental Sounds in Auditory Agnosia) questionnaire, the ADQRL (Alzheimer’s Disease-Related Quality of Life) scale, and speech and tone audiometry.
Results
Some 57 % of our 34 participants showed clinical signs of auditory agnosia for environmental sounds, and 47 % had undetected hearing loss to such an extent that it made them eligible for a hearing aid. Although the two factors appear to be independent, their joint effect can impact people’s daily functioning. Nonetheless, we found them to have only little impact on the participants’ quality of life as measured by the ADQRL, possibly because most of them lived in a sheltered environment, and some moreover showed anosognosia for their agnosia.
Conclusion
Difficulties recognizing environmental sounds in daily life are very common in people with Alzheimer’s disease. Although we found no direct relation with quality of life as measured by a questionnaire, awareness of auditory agnosia for environmental sounds is still important since it may help explain why function declines. The additional finding that 47 % of people in this group had unrecognized hearing loss shows that self-assessment of hearing is often inaccurate in Alzheimer’s disease, with implications for daily practice where clinicians might only explore hearing loss when acknowledged by their patient. On the basis of our findings we advise further longitudinal, multi-year studies of hearing screening and rehabilitation in Alzheimer’s disease, if possible starting during its prodromal stage, something supported by findings in a large trials suggesting that hearing interventions might be slowing cognitive decline in an older population at risk of this
Estimated atrial fibrillation burden on early rhythm-control and cardiovascular events in the EAST-AFNET 4 trial
Get PDFBACKGROUND: Atrial fibrillation (AF) is currently diagnosed by ECG, creating a binary, lifelong diagnosis. AF burden, estimated as the proportion of time spent in AF, quantifies AF severity dynamically. AF burden can modulate the risk of AF-related outcomes. Whether AF burden modulates cardiovascular outcomes with rhythm-control therapy is unknown. METHODS: AF burden on early rhythm-control was estimated using supervised artificial-intelligence-based rhythm classification of patient-operated telemetric short-term ECGs in patients randomised to early rhythm-control in the EAST-AFNET 4 trial (NCT01288352, ISRCTN04708680, conducted between 2011 and 2020). ECGs were transmitted 1-2 times per week and during symptoms. A landmark was set at 12 months and efficacy and safety outcomes occurring during the subsequent 4.1 years of follow-up were compared by estimated AF burden quartiles (Q1-Q4). FINDINGS: In 1178 patients (70 years, 47% women, CHA2DS2-VA 2.8 ± 1.2) transmitting 303,308 ECGs over 5.1 years, (median 1/week, IQR 1; 2) estimated AF burden was 6% [0%; 22%] in the first year of follow-up. Estimated AF burden below the median was associated with low rates of cardiovascular death, stroke, or unplanned hospitalisation for heart failure or acute coronary syndrome (Q1: 2.0 events/100 patient-years; Q2: 2.6 events/100 patient-years). A higher estimated AF burden was associated with higher event rates (Q3: 4.8 events/100 patient-years; Q4: 4.2 events/100 patient-years), comparable to events with usual care (4.5 events/100 patient-years). Sensitivity analyses confirmed these findings. INTERPRETATION: These hypothesis-generating findings suggest that AF burden estimated by weekly short-term patient-operated ECGs modulates AF-related events on rhythm-control therapy. Pending validation and evaluation of residual confounding, estimation of AF burden can refine AF diagnosis. FUNDING: EAST-AFNET4 was supported by a grant from the German Ministry of Education and Research (01 GI0204) via the German Center for Cardiovascular Research (DZHK), the Atrial Fibrillation NETwork (AFNET), the European Heart Rhythm Association, St. Jude Medical/Abbott, Sanofi, and the German Heart Foundation. These analyses received additional support from the European Union (grant agreement 965286 [MAESTRIA]), British Heart Foundation (AA/18/2/34218), German Center for Cardiovascular Research supported by the German Ministry of Education and Research (DZHK, grant numbers DZHK FKZ 81X2800182, 81Z0710116, and 81Z0710110), German Research Foundation (Ki 509167694) and the Else Kröner-Fresenius Foundation, Dutch Heart Foundation (Grant number 01-002-2022-0118, EmbRACE), and the Leducq Foundation (2024, Immune Targets for Atrial Fibrillation)
Epidemiology of sepsis in hospitalised neonates in Indonesia: high burden of multidrug-resistant infections reveals poor coverage provided by recommended antibiotic regimens
Get PDFBackground
Neonatal sepsis is a leading cause of child mortality, and this burden is rising secondary to increasing antimicrobial resistance worldwide. There are marked global disparities in the burden of antimicrobial resistance, with Southeast Asia identified as a region of particular concern. Indonesia is the world’s fourth most populous country, with 4.2 million babies born each year. Despite this, there remains limited published data on the burden of neonatal sepsis and antimicrobial resistance in the country.
Methods
We conducted a 2-year analysis of the epidemiology of neonatal sepsis across three high-burden clinical settings in Indonesia, alongside an antibiotic point prevalence prescribing survey.
Results
Of 5439 blood cultures analysed, gram-negative bacteria predominated as causative pathogens for neonatal sepsis in Indonesia, with Klebsiella spp and Acinetobacter spp most common (prevalence 35% and 19%, respectively). Overall, the pathogens causing neonatal sepsis exhibit very low susceptibility to WHO-recommended antibiotic regimens for the treatment of neonatal sepsis, with only 25% coverage provided by aminopenicillins plus gentamicin (95% credible interval (CI) 22% to 29%) and 20% by third-generation cephalosporins (95% CI 17% to 23%). Almost half of all antibiotics prescribed to treat neonatal sepsis across the clinical settings included in our study were Watch and Reserve antibiotics.
Conclusion
Our multicentre study across three sites in Indonesia revealed neonatal sepsis is predominantly caused by Gram-negative pathogens, with very poor coverage provided by currently recommended empiric regimens. A high burden of multidrug-resistant pathogens drives empirical use of broad-spectrum antibiotics. There is an urgent need for new antibiotic regimens and infection prevention and control strategies to treat neonatal sepsis in regions with a high prevalence of multidrug-resistant infections
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