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A study by Dr Nathalie Conrad and Prof Kazaem Rahimi at the George Institute (Nuffield Department of Women's and Reproductive Health) finds that women and older people are most likely to be exposed to shortcomings in heart failure care.
Systematic reviews and accompanying meta-analyses of high-quality studies are at the top of the evidence pyramid. By synthesising the totality of evidence they can address a variety of clinical and research questions. Although they were initially effectiveness and safety of health interventions, systematic reviews (with or without meta-analysis) are now also common in the evaluation of diagnostic test accuracy, prognostic factors, prediction models, prevalence of disease, cost-effectiveness and other areas. With increasing numbers of systematic reviews, clinicians, consumers, and policy makers usually need to refer to a large number of systematic reviews to inform clinical decision-making.
Aortic balloon for the intraoperative management of placenta accreta spectrum: need for standardised methodology and safety data.
In 2003, Bell-Thomas et al (BJOG 2003;110:1120-1122) reported on the emergency use of a transfemoral aortic occlusion catheter to control massive haemorrhage in a case of caesarean hysterectomy for placenta percreta. This was only the second case published in the international literature on the use of an intra-abdominal aortic balloon occlusion (IABO) in the management of placenta accreta spectrum (PAS) (Paull et al. Anesth Intensive Care 1995;23:731-734).
Preterm birth (PTB, <37 weeks) is the leading cause of death in children <5 years of age. Early risk prediction for PTB would enable early monitoring and intervention. However, such prediction models have been rarely reported, especially in low- and middle-income areas. We used data on a number of easily accessible predictors during early pregnancy from 9044 women in Born in Guangzhou Cohort Study, China to generate prediction models for overall PTB and spontaneous, iatrogenic, late (34–36 weeks), and early (<34 weeks) PTB. Models were constructed using the Cox proportional hazard model, and their performance was evaluated by Harrell’s c and D statistics and calibration plot. We further performed a systematic review to identify published models and validated them in our population. Our new prediction models had moderate discrimination, with Harrell’s c statistics ranging from 0.60–0.66 for overall and subtypes of PTB. Significant predictors included maternal age, height, history of preterm delivery, amount of vaginal bleeding, folic acid intake before pregnancy, and passive smoking during pregnancy. Calibration plots showed good fit for all models except for early PTB. We validated three published models, all of which were from studies conducted in high-income countries; the area under receiver operating characteristic for these models ranged from 0.50 to 0.56. Based on early pregnancy characteristics, our models have moderate predictive ability for PTB. Future studies should consider inclusion of laboratory markers for the prediction of PTB.
© 2020 The Author(s) Zika virus (ZIKV) is a mosquito-borne, single-stranded DNA flavivirus that is teratogenic and neurotropic. Similar to the teratogenic effects of other TORCH infections, ZIKV infection during pregnancy can have an adverse impact on fetal and neonatal development. Epilepsy is detected in 48–96% of children with Congenital Zika Syndrome (CZS) and microcephaly. Early epilepsy surveillance is needed in children with prenatal ZIKV exposure; yet, most ZIKV-endemic regions do not have specialist epilepsy care. Here, we describe the demographic, clinical, imaging, and EEG characteristics of a 2-year-old child with CZS and microcephaly who presented with focal epileptiform activity, suboptimal growth, and severe neurodevelopmental delays. Administration of a brief seizure questionnaire by allied health professionals to the patient's caregiver helped to characterize the child's seizure semiology and differentiate focal from generalized seizure features. A telemedicine EEG interpretation platform provided valuable diagnostic information for the patient's local pediatrician to integrate into her treatment plan. This case illustrates that CZS can present with focal epilepsy features and that a telemedicine approach can be used to bridge the gap between epilepsy specialists and local care providers in resource limited ZIKV-endemic regions to achieve better seizure control in children with CZS.
Derivation and Validation of a Nomogram for Predicting 90-Day Survival in Patients With HBV-Related Acute-on-Chronic Liver Failure.
Background: Conventional prognostic models do not fully reflect the severity of hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF). This study aimed to establish an effective and convenient nomogram for patients with HBV-related ACLF. Methods: A nomogram was developed based on a retrospective cohort of 1,353 patients treated at the Third Affiliated Hospital of Sun Yat-sen University from January 2010 to June 2016. The predictive accuracy and discriminatory ability of the nomogram were determined by a concordance index (C-index) and calibration curve, and were compared with current scoring systems. The results were validated using an independent retrospective cohort of 669 patients consecutively treated at the same institution from July 2016 to March 2018. This study is registered at ClinicalTrials.gov (NCT03992898). Results: Multivariable analysis of the derivation cohort found that independent predictors of 90-day survival were age, white blood cell (WBC) count, hemoglobin (Hb), aspartate aminotransferase (AST), total bilirubin (TBil), international normalized ratio, serum creatinine (Cr), alpha fetoprotein (AFP), serum sodium (Na), hepatic encephalopathy (HE), pre-existing chronic liver disease(PreLD), and HBV DNA load. All factors were included in the nomogram. The nomogram calibration curve for the probability of 90-day survival indicated that nomogram-based predictions were in good agreement with actual observations. The C-index of the nomogram was 0.790, which was statistically significantly greater than those for the current scoring systems in the derivation cohort (P < 0.001). The results were confirmed in the validation cohort. Conclusions: The proposed nomogram is more accurate in predicting the 90-day survival of patients with HBV-related ACLF than current commonly used methods.
Increasing trends in incidence of preterm birth among 2.5 million newborns in Guangzhou, China, 2001 to 2016: an age-period-cohort analysis
Abstract Background The incidence of preterm birth (PTB, < 37 weeks of gestation) has been increasing in China and many other countries in recent years. However, the causes of the increase were not well understood. The current study aims to examine the contribution of maternal age, period of delivery, and maternal birth cohorts to long-term trends in preterm birth in Guangzhou, China. Methods In a retrospective population-based study, data were obtained from 2,535,000 singleton live births with 20–43 gestational weeks from 2001 to 2016 and recorded in the Guangzhou Perinatal Health Care and Delivery Surveillance System, in China. The age-period-cohort models were applied to investigate the temporal changes in incidences of PTB, stratified by parity. Results The incidence of preterm birth steadily increased from 5.1% in 2001 to 5.9% in 2016, with larger rise in primiparous mothers (from 5.0 to 5.9%) compared to multiparous mothers (from 5.6 to 5.9%). A J-shaped and a V-shaped relationship were found between maternal age and PTB among primiparous and multiparous mothers, respectively. A linear cohort effect was found among primiparous mothers with the lowest risk of PTB [risk ratio (RR) = 0.81, 95% confidence interval (CI): 0.74 to 0.89] in 1961 and the highest risk (RR = 1.06, 95% CI: 1.00 to 1.13) in 1997 compared to the mothers born in 1981. An inverse U-shaped association between maternal birth cohort and PTB was found in multiparous mothers. There were weak decreasing period effects on the trend of overall PTB among multiparous mothers and on the trend of extremely (< 27 weeks) or very (28–31 weeks) PTB among both parity groups during the period of 2001–2012. Conclusions Our findings showed the PTB incidences had been increasing in the past 16 years in Guangzhou, China and both maternal age and cohort effects contributed to these trends. Further studies are recommended on the impact of altered maternal age and parity on premature births and corresponding public education and public health policies.
BACKGROUND: Birth weight is a strong determinant of infant short- and long-term health outcomes. Family socioeconomic position (SEP) is usually positively associated with birth weight. Whether this association extends to abnormal birth weight or there exists potential mediator is unclear. METHODS: We analyzed data from 14,984 mother-infant dyads from the Born in Guangzhou Cohort Study. We used multivariable logistic regression to assess the associations of a composite family SEP score quartile with macrosomia and low birth weight (LBW), and examined the potential mediation effect of maternal pre-pregnancy body mass index (BMI) using causal mediation analysis. RESULTS: The prevalence of macrosomia and LBW was 2.62% (n = 392) and 4.26% (n = 638). Higher family SEP was associated with a higher risk of macrosomia (OR 1.30, 95% CI 0.93-1.82; OR 1.53, 95% CI 1.11-2.11; and OR 1.59, 95% CI 1.15-2.20 for the 2nd, 3rd, and 4th SEP quartile respectively) and a lower risk of LBW (OR 0.69, 95% CI 0.55-0.86; OR 0.76, 95% CI 0.61-0.94; and OR 0.61, 95% CI 0.48-0.77 for the 2nd, 3rd, and 4th SEP quartile respectively), compared to the 1st SEP quartile. We found that pre-pregnancy BMI did not mediate the associations of SEP with macrosomia and LBW. CONCLUSIONS: Socioeconomic disparities in fetal macrosomia and LBW exist in Southern China. Whether the results can be applied to other populations should be further investigated.
A cross-sectional comparison of epidemiological and clinical features of patients with coronavirus disease (COVID-19) in Wuhan and outside Wuhan, China.
BACKGROUND: Coronavirus disease 2019 (COVID-19) has spread outside the initial epicenter of Wuhan. We compared cases in Guangzhou and Wuhan to illustrate potential changes in pathogenicity and epidemiological characteristics as the epidemic has progressed. METHODS: We studied 20 patients admitted to the Third Affiliated Hospital of Sun Yat-Sen University in Guangzhou, China from January 22 to February 12, 2020. Data were extracted from medical records. These cases were compared with the 99 cases, previously published in Lancet, from Wuhan Jinyintan Hospital from January 1 to January 20, 2020. RESULTS: Guangzhou patients were younger and had better prognosis than Wuhan patients. The Wuhan patients were more likely to be admitted to the ICU (23% vs 5%) and had a higher mortality rate (11% vs 0%). Cases in Guangzhou tended to be more community clustered. Diarrhea and vomiting were more common among Guangzhou patients and SARS-CoV-2 RNA was found in feces. Fecal SARA-CoV-2 RNA remained positive when nasopharyngeal swabs turned negative in some patients. CONCLUSIONS: This study indicates possible diminishing virulence of the virus in the process of transmission. Yet persistent positive RNA in feces after negative nasopharyngeal swabs suggests a possible prolonged transmission period that challenges current quarantine practices.
Compare the epidemiological and clinical features of imported and local COVID-19 cases in Hainan, China.
BACKGROUND: Effective management of imported cases is an important part of epidemic prevention and control. Hainan Province, China reported 168 coronavirus disease 2019 (COVID-19), including 112 imported cases on February 19, 2020, but successfully contained the epidemic within 1 month. We described the epidemiological and clinical characteristics of COVID-19 in Hainan and compared these features between imported and local cases to provide information for other international epidemic areas. METHODS: We included 91 patients (56 imported and 35 local cases) from two designated hospitals for COVID-19 in Haikou, China, from January 20 to February 19, 2020. Data on the demographic, epidemiological, clinical and laboratory characteristics were extracted from medical records. Patients were followed until April 21, 2020, and the levels of antibodies at the follow-ups were also analysed by the Wilcoxon matched-pairs signed ranks test. RESULTS: Of the 91 patients, 78 (85.7%) patients were diagnosed within the first three weeks after the first case was identified (Day 1: Jan 22, 2020), while the number of local cases started to increase during the third week. No new cases occurred after Day 29. Fever and cough were two main clinical manifestations. In total, 15 (16.5%) patients were severe, 14 (15.4%) had complicated infections, nine (9.9%) were admitted to the intensive care unit, and three died. The median duration of viral shedding in feces was longer than that in nasopharyngeal swabs (19 days vs 16 days, P = 0.007). Compared with local cases, imported cases were older and had a higher incidence of fever and concurrent infections. There was no difference in outcomes between the two groups. IgG was positive in 92.8% patients (77/83) in the follow-up at week 2 after discharge, while 88.4% patients (38/43) had a reduction in IgG levels in the follow-up at week 4 after discharge, and the median level was lower than that in the follow-up at week 2 (10.95 S/Cut Off (S/CO) vs 15.02 S/CO, P
BACKGROUND: Technological advances and high throughput biological assays can facilitate discovery science in biobanks from population cohorts, including pregnant women. Biological pathways associated with health outcomes differ depending on geography, and high-income country data may not generalise to low-resource settings. We conducted a systematic review to identify prospective pregnancy cohorts in sub-Saharan Africa (SSA) that include biobanked samples with potential to enhance discovery science opportunity. METHODS: Inclusion criteria were prospective data collection during pregnancy, with associated biobanking in SSA. Data sources included: scientific databases (with comprehensive search terms), grey literature, hand searching applicable reference lists and expert input. Results were screened in a three-stage process based on title, abstract and full text by two independent reviewers. The review is registered on PROSPERO (CRD42019147483). RESULTS: Fourteen SSA studies met the inclusion criteria from database searches (n=8), reference list searches (n=2) and expert input (n=4). Three studies have ongoing data collection. The most represented countries were South Africa and Mozambique (Southern Africa) (n=3), Benin (Western Africa) (n=4) and Tanzania (Eastern Africa) (n=4); including an estimated 31 763 women. Samples commonly collected were blood, cord blood and placenta. Seven studies collected neonatal samples. Common clinical outcomes included maternal and perinatal mortality, malaria and preterm birth. CONCLUSIONS: Increasingly numerous pregnancy cohorts in SSA that include biobanking are generating a uniquely valuable resource for collaborative discovery science, and improved understanding of the high regional risks of maternal, fetal and neonatal morbidity and mortality. Future studies should align protocols and consider their added value and distinct contributions.
© 2020, Springer Nature Switzerland AG. For many emerging medical image analysis problems, there is limited data and associated annotations. Traditional deep learning is not well-designed for this scenario. In addition, for deploying deep models on a consumer-grade tablet, it requires models to be efficient computationally. In this paper, we describe a framework for automatic quality assessment of freehand fetal ultrasound video that has been designed and built subject to constraints such as those encountered in low-income settings: ultrasound data acquired by minimally trained users, using a low-cost ultrasound probe and android tablet. Here the goal is to ensure that each video contains good neurosonography biometry planes for estimating the head circumference (HC) and transcerebellar diameter (TCD). We propose a label efficient learning framework for this purpose that it turns out generalises well to unseen data. The framework is semi-supervised consisting of two major components: 1) a prototypical learning module that learns categorical embeddings implicitly to prevent the model from overfitting; and, 2) a semantic transfer module (to unlabelled data) that performs “temperature modulated” entropy minimization to encourage a low-density separation of clusters along categorical boundaries. The trained model is deployed on an Andriod tablet via TensorFlow Lite and we report on real-time inference with the deployed models in terms of model complexity and performance.
Developing Visual Messages to Support Liquefied Petroleum Gas Use in Intervention Homes in the Household Air Pollution Intervention Network (HAPIN) Trial in Rural Guatemala
Background: Household air pollution adversely affects human health and the environment, yet more than 40% of the world still depends on solid cooking fuels. The House Air Pollution Intervention Network (HAPIN) randomized controlled trial is assessing the health effects of a liquefied petroleum gas (LPG) stove and 18-month supply of free fuel in 3,200 households in rural Guatemala, India, Peru, and Rwanda. Aims: We conducted formative research in Guatemala to create visual messages that support the sustained, exclusive use of LPG in HAPIN intervention households. Method: We conducted ethnographic research, including direct observation (n = 36), in-depth (n = 18), and semistructured (n = 6) interviews, and 24 focus group discussions (n = 96) to understand participants’ experience with LPG. Sixty participants were selected from a pilot study of LPG stove and 2-months of free fuel to assess the acceptability and use of LPG. Emergent themes were used to create visual messages based on observations and interviews in 40 households; messages were tested and revised in focus group discussions with 20 households. Results: We identified 50 codes related to household air pollution and stoves; these were reduced into 24 themes relevant to LPG stoves, prioritizing 12 for calendars. Messages addressed fear and reluctance to use LPG; preference of wood stoves for cooking traditional foods; sustainability and accessibility of fuel; association between health outcomes and household air pollution; and the need for inspirational and aspirational messages. Discussion: We created a flip chart and calendar illustrating themes to promote exclusive LPG use in HAPIN intervention households.