Background Managing risk factors is crucial to prevent stroke. However, few cohort studies have evaluated socioeconomic factors together with conventional factors affecting incident stroke and its ...subtypes in China. Methods and Results A 2014 to 2016 prospective study from the China National Stroke Screening and Intervention Program comprised 437 318 adults aged ≥40 years without stroke at baseline. There were 2429 cases of first-ever stroke during a median follow-up period of 2.1 years, including 2206 ischemic strokes and 237 hemorrhagic strokes. The multivariable Cox regression analysis indicated that age 50 to 59 years (versus 40-49 years), primary school or no formal education (versus middle school), having >1 child (versus 1 child), living in Northeast, Central, East, or North China (versus Southwest China), physical inactivity, hypertension, diabetes mellitus, and obesity were positively associated with the risk of total and ischemic stroke, whereas age 60 to 69 years and living with spouse or children (versus living alone) were negatively associated with the risk of total and ischemic stroke. Men, vegetable-based diet, underweight, physical inactivity, hypertension, living in a high-income region, having Urban Resident Basic Medical Insurance, and New Rural Cooperative Medical System were positively associated with the risk of hemorrhagic stroke, whereas age 60 to 69 years was negatively associated with the risk of hemorrhagic stroke. Conclusions We identified socioeconomic factors that complement traditional risk factors for incident stroke and its subtypes, allowing targeting these factors to reduce stroke burden.
Introduction
Preterm birth (PTB) is the leading cause of infant mortality and morbidity worldwide. Rates of PTB in the Netherlands are declining, possibly due to the implementation of preventive ...strategies. In this study we assessed the overall trend in PTB rates in the Netherlands in recent years, and in more detail in specific subgroups to investigate potential groups that require scrutiny in the near future.
Material and methods
Based on the national perinatal registry, we included all pregnancies without severe congenital abnormalities resulting in a birth from 24 to 42 completed weeks of gestation between 2011 and 2019 in the Netherlands. We assessed PTB rates in two different clinical subtypes (spontaneous vs. iatrogenic) and in five gestational age subgroups: 24–27+6 weeks (extreme), 28–31+6 weeks (very), 32–33+6 weeks (moderate, 34–36+6 weeks late and, in general, 24–36+6 weeks overall PTB). Trend analysis was performed using the Cochran Armitage test. We also compared PTB rates in different subgroups in the first 2 years compared to the last 2 years. Singleton and multiple gestations were analyzed separately.
Results
We included 1 447 689 singleton and 23 250 multiple pregnancies in our study. In singletons, we observed a significant decline in PTB from 5.5% to 5.0% (p < 0.0001), mainly due to a decrease in iatrogenic PTBs. When focusing on different gestational age subgroups, there was a decrease in all iatrogenic PTB and in moderate to late spontaneous PTB. However, in spontaneous extreme and very PTB there was an significant increase. When assessing overall PTB risk in different subgroups, the decline was only visible in women with age ≥25 years, nulliparous and primiparous women, women with a medium or high socioeconomic status and hypertensive women. In multiples, the rate of PTB remained fairly stable, from 52.3% in 2011 to 54.1% in 2019 (p = 0.57).
Conclusions
In the Netherlands, between 2011 and 2019, PTB decreased, mainly due to a reduction in late PTB, and more in iatrogenic than in spontaneous PTB. Focus for the near future should be on specific subgroups in which the decline was not visible, such as women with a low socioeconomic status or a young age.
This study assessed recent trends preterm birth (PTB) rates in the Netherlands. Between 2011 and 2019, PTB rates decreased, mainly due to a reduction in late PTB, and more in iatrogenic than in spontaneous PTB.
Women of Black and other non-Western ethnicity and women who live in deprived neighborhoods are at increased risk for preterm birth (PTB). These women may live clustered in certain urban areas. If ...ethnicity reflects a biological rather than a socioeconomic risk factor, women should have a PTB risk independent of the urban area where they live. In this study we explored the association between urban living and the risk of PTB, combined with knowledge on ethnicity and neighborhood deprivation in these specific urban areas in the Netherlands.
National cohort study of 935,381 women (2014–2019) with a singleton pregnancy resulting in live birth between 24.0 and 42.6 weeks. Antepartum death and severe congenital anomalies were excluded. We performed logistic regression analysis and analyzed the impact of living in one of the four main urban areas on PTB. We adjusted for maternal age, parity and fetal gender. We tested for interaction between ethnicity, neighborhood deprivation index (NDI) and urban living.
Mean PTB rate among singleton pregnancies in The Netherlands is 5.1%. There was a strong ethnic difference in PTB risk, with the highest prevalence among South Asian women (7.9%) and African women (6.6%). In the most deprived neighborhoods the PTB risk was 5.7%. We found a significant interaction between ethnicity and urban living, and between NDI and urban living. South Asian and African women living in urban areas had the greatest risk of PTB, between 7.0% and 8.8%.
Ethnicity remains a fixed biological risk for PTB that cannot be fully explained by socioeconomic status or neighborhood deprivation. Independent of ethnicity and neighborhood deprivation, urban living has a great influence on the risk of preterm birth. Future studies and policies should focus on population-based interventions in those urban areas where South Asian and African ethnic groups live and where the preterm birth risk is the highest.
Background
The currently available mortality prediction models (MPM) have suboptimal performance when predicting early mortality (30‐days) following transcatheter aortic valve implantation (TAVI) on ...various external populations. We developed and validated a new TAVI‐MPM based on a large number of predictors with recent data from a national heart registry.
Methods
We included all TAVI‐patients treated in the Netherlands between 2013 and 2018, from the Netherlands Heart Registration. We used logistic‐regression analysis based on the Akaike Information Criterion for variable selection. We multiply imputed missing values, but excluded variables with >30% missing values. For internal validation, we used ten‐fold cross‐validation. For temporal (prospective) validation, we used the 2018‐data set for testing. We assessed discrimination by the c‐statistic, predicted probability accuracy by the Brier score, and calibration by calibration graphs, and calibration‐intercept and calibration slope. We compared our new model to the updated ACC‐TAVI and IRRMA MPMs on our population.
Results
We included 9144 TAVI‐patients. The observed early mortality was 4.0%. The final MPM had 10 variables, including: critical‐preoperative state, procedure‐acuteness, body surface area, serum creatinine, and diabetes‐mellitus status. The median c‐statistic was 0.69 (interquartile range IQR 0.646–0.75). The median Brier score was 0.038 (IQR 0.038–0.040). No signs of miscalibration were observed. The c‐statistic's temporal‐validation was 0.71 (95% confidence intervals 0.64–0.78). Our model outperformed the updated currently available MPMs ACC‐TAVI and IRRMA (p value < 0.05).
Conclusion
The new TAVI‐model used additional variables and showed fair discrimination and good calibration. It outperformed the updated currently available TAVI‐models on our population. The model's good calibration benefits preprocedural risk‐assessment and patient counseling.
Background
An early and proper diagnosis of acute on chronic liver failure (ACLF), together with the identification of indicators associated with disease severity is critical for outcome prediction ...and therapy.
Objective
To systematically identify and summarize prognostic indicators for patients with ACLF and to evaluate the predictive value of these indicators.
Methods
Embase and Ovid‐Medline were searched for English‐language articles. The search criteria focused on identifying clinical trials and observational studies reporting on indicators used for prediction of mortality in patients with ACLF.
Results
Of 2382 studies identified, 19 were included for detailed analysis. Thirteen different definitions of ACLF were found. The main differences were related to acute deterioration in liver function, coagulopathy and hyperbilirubinaemia/jaundice. Seventy three prognostic indicators and their association with mortality were extracted and categorized into seven categories: general markers (n = 13), viral markers (n = 6), bio‐markers (n = 22), hemodynamics (n = 1), morphology/histology (n = 17), scoring systems (n = 10) and treatments (n = 4).
Conclusions
The ambiguity and variability in the definition of ACLF and in its predictive indicators hampers comparability among studies. There is a need for a single uniform definition of ACLF. Also absence of a gold standard is an obstacle to render one indicator superior to another. The age, hepatic encephalopathy, model for end‐stage liver disease score, total bilirubin and International normalized ratio (prothrombin time) appeared to be promising candidates for evaluation in future studies. The result of this review may be useful as a starting point in developing a standard list of indicators for clinical outcome that concur with the clinicians' subjective views on prognosis in ACLF.
Introduction
The associations of epidural analgesia and low Apgar score found in the Swedish Registry might be a result of confounding by indication. The objective of this study was to assess the ...possible effect of intrapartum epidural analgesia on low Apgar score and neonatal intensive care unit (NICU) admission in term born singletons with propensity score matching.
Material and methods
This was a propensity score matched study (n = 257 872) conducted in a national cohort of 715 449 term live born singletons without congenital anomalies in the Netherlands. Mothers with prelabor cesarean section were excluded. Main outcome measures were 5‐minute Apgar score <7, 5‐minute Apgar score <4 and admission to a NICU for at least 24 hours. First, an analysis of the underlying risk factors for low Apgar score <7 was performed. Multivariable analyses were applied to assess the effect of the main risk factor, intrapartum epidural analgesia, on low Apgar score to adjust the results for confounding factors. Second, a propensity score matched analysis on the main risk factors for epidural analgesia was applied. By propensity score matching the (confounding) characteristics of the women who received epidural analgesia with the characteristics of the control women without epidural analgesia, the effect of possible confounding by indication is minimized.
Results
Intrapartum epidural analgesia was performed in 128 936 women (18%). Apgar score <7 was present in 1.0%, Apgar score <4 in .2% and NICU admission in .4% of the deliveries. The strongest risk factor for Apgar score <7 was epidural analgesia (adjusted odds ratio aOR 1.9, 95% confidence interval CI 1.8‐2.0). The propensity score matched adjusted analysis of women with epidural analgesia showed significant adverse neonatal outcomes: aOR 1.8 (95% CI 1.7‐1.9) for AS <7, aOR 1.6 (95% CI 1.4‐1.9) for AS <4 and aOR 1.7 (95% CI 1.6‐1.9) for NICU admission. The results of epidural analgesia on AS <7 were also significantly increased for spontaneous start of labor (aOR 2.0, 95% CI 1.8‐2.1) and for spontaneous delivery.
Conclusions
Intrapartum epidural analgesia at term is strongly associated with low Apgar score and more NICU admissions, especially in spontaneous deliveries. This association needs further research and awareness.
Although previous studies suggest similar patient survival for peritoneal dialysis (PD) and haemodialysis (HD), PD use has decreased worldwide. We aimed to study trends in the choice of first ...dialysis modality and relate these to variation in patient and technique survival and kidney transplant rates in Europe over the last 20 years.
We used data from 196 076 patients within the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry who started renal replacement therapy (RRT) between 1993 and 2012. Trends in the incidence rate and prevalence on Day 91 after commencing RRT were quantified with Joinpoint regression. Crude and adjusted hazard ratios (HRs) for 5-year dialysis patient and technique survival were calculated using Cox regression. Analyses were repeated using propensity score matching to control for confounding by indication.
PD prevalence dropped since 2007 and HD prevalence stabilized since 2009. Incidence rates of PD and HD decreased from 2000 and 2009, respectively, while the incidence of kidney transplantation increased from 1993 onwards. Similar 5-year patient survival for PD versus HD patients was found in 1993-97 adjusted HR: 1.02, 95% confidence interval (95% CI): 0.98-1.06, while survival was higher for PD patients in 2003-07 (HR: 0.91, 95% CI: 0.88-0.95). Both PD (HR: 0.95, 95% CI: 0.91-1.00) and HD technique survival (HR: 0.93, 95% CI: 0.87-0.99) improved in 2003-07 compared with 1993-97.
Although initiating RRT on PD was associated with favourable patient survival when compared with starting on HD treatment, PD was often not selected as initial dialysis modality. Over time, we observed a significant decline in PD use and a stabilization in HD use. These observations were explained by the lower incidence rate of PD and HD and the increase in pre-emptive transplantation.
The aim of this scoping review is to summarize approaches and outcomes of clinical validation studies of clinical decision support systems (CDSSs) to support (part of) a medication review. A ...literature search was conducted in Embase and Medline. In total, 30 articles validating a CDSS were ultimately included. Most of the studies focused on detection of adverse drug events, potentially inappropriate medications and drug‐related problems. We categorized the included articles in three groups: studies subjectively reviewing the clinical relevance of CDSS's output (21/30 studies) resulting in a positive predictive value (PPV) for clinical relevance of 4–80%; studies determining the relationship between alerts and actual events (10/30 studies) resulting in a PPV for actual events of 5–80%; and studies comparing output of CDSSs to chart/medication reviews in the whole study population (10/30 studies) resulting in a sensitivity of 28–85% and specificity of 42–75%. We found heterogeneity in the methods used and in the outcome measures. The validation studies did not report the use of a published CDSS validation strategy. To improve the effectiveness and uptake of CDSSs supporting a medication review, future research would benefit from a more systematic and comprehensive validation strategy.
Introduction
This study aimed to assess whether induction of labor at 41 weeks of gestation improved perinatal outcomes in a low‐risk pregnancy compared with expectant management.
Material and ...methods
Registry‐based national cohort study in The Netherlands. The study population comprised 239 971 low‐risk singleton pregnancies from 2010 to 2019, with birth occurring from 41+0 to 42+0 weeks. We used propensity score matching to compare induction of labor in three 2‐day groups to expectant management, and further conducted separate analyses by parity. The main outcome measures were stillbirth, perinatal mortality, 5‐min Apgar <4 and <7, neonatal intensive care unit (NICU) admissions ≥24 h, and emergency cesarean section rate.
Results
Compared with expectant management, induction of labor at 41+0 to 41+1 weeks resulted in reduced stillbirths (adjusted odds ratio aOR 0.15, 95% confidence interval CI 0.05–0.51) in both nulliparous and multiparous women. Induction of labor increased 5‐min Apgar score <7 (aOR 1.30, 95% CI 1.09–1.55) and NICU admissions ≥24 h (aOR 2.12, 95% CI 1.53–2.92), particularly in nulliparous women, and increased the cesarean section rate (aOR 1.42, 95% CI 1.34–1.51). At 41+2–41+3 weeks, induction of labor reduced perinatal mortality (aOR 0.13, 95% CI 0.04–0.43) in both nulliparous and multiparous women. The rate of 5‐min Apgar score <7 was increased (aOR 1.26, 95% CI 1.06–1.50), reaching significance in multiparous women. The cesarean section rate increased (aOR 1.57, 95% CI 1.48–1.67) in both nulliparous and multiparous women. Induction of labor at 41+4 to 41+5 weeks reduced stillbirths (aOR 0.30, 95% CI 0.10–0.93). Induction of labor increased rates of 5‐min Apgar score <4 (aOR 1.61, 95% CI 1.01–2.56) and NICU admissions ≥24 h (aOR 1.52, 95% CI 1.08–2.13) in nulliparous women. Cesarean section rate was increased (aOR 1.47, 95% CI 1.38–1.57) in nulliparous and multiparous women.
Conclusions
At 41+2 to 41+3 weeks, induction of labor reduced perinatal mortality, and in all 2‐day groups at 41 weeks, it reduced stillbirths, compared with expectant management. Low 5‐min Apgar score (<7 and <4) and NICU admissions ≥24 h occurred more often with induction of labor, especially in nulliparous women. Induction of labor in all 2‐day groups coincided with elevated cesarean section rates in nulliparous and multiparous women. These findings pertaining to the choice of induction of labor vs expectant management should be discussed when counseling women at 41 weeks of gestation.
Induction of labor in a low‐risk population at 41 weeks was independently associated with reduced perinatal deaths but increased rates of lower 5‐min Apgar scores (<4 and <7) and NICU admissions, and higher emergency CS rates as compared with expectant management in all 2‐day groups.
Highlights • 40% of ACOVE indicators can be automatically evaluated in Dutch general practice. • Sub-optimal statement of indicators impedes automatic evaluation of healthcare. • Modification of GP ...databases is required to optimize evaluation of healthcare. • LERM is feasible method for analyzing clinical rules in quality evaluation.
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