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.
Patients admitted to the intensive care unit (ICU) are frequently exposed to potential drug‐drug interactions (pDDIs). However, reported frequencies of pDDIs in the ICU vary widely between studies. ...This can be partly explained by significant variation in their methodological approach. Insight into methodological choices affecting pDDI frequency would allow for improved comparison and synthesis of reported pDDI frequencies. This study aimed to evaluate the association between methodological choices and pDDI frequency and formulate reporting recommendations for pDDI frequency studies in the ICU. The MEDLINE database was searched to identify papers reporting pDDI frequency in ICU patients. For each paper, the pDDI frequency and methodological choices such as pDDI definition and pDDI knowledge base were extracted, and the risk of bias was assessed. Each paper was categorized as reporting a low, medium, or high pDDI frequency. We sought associations between methodological choices and pDDI frequency group. Based on this comparison, reporting recommendations were formulated. Analysis of methodological choices showed significant heterogeneity between studies, and 65% of the studies had a medium to high risk of bias. High risk of bias, small sample size, and use of drug prescriptions instead of administrations were related to a higher pDDI frequency. The findings of this review may support researchers in designing a reliable methodology assessing pDDI frequency in ICU patients. The reporting recommendations may contribute to standardization, comparison, and synthesis of pDDI frequency studies, ultimately improving knowledge about pDDIs in and outside the ICU setting.
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.
Abstract
Background
Currently used prediction tools have limited ability to identify community-dwelling older people at high risk for falls. Prediction models utilizing electronic health records ...(EHRs) provide opportunities but up to now showed limited clinical value as risk stratification tool, because of among others the underestimation of falls prevalence. The aim of this study was to develop a fall prediction model for community-dwelling older people using a combination of structured data and free text of primary care EHRs and to internally validate its predictive performance.
Methods
We used EHR data of individuals aged 65 or older. Age, sex, history of falls, medications, and medical conditions were included as potential predictors. Falls were ascertained from the free text. We employed the Bootstrap-enhanced penalized logistic regression with the least absolute shrinkage and selection operator to develop the prediction model. We used 10-fold cross-validation to internally validate the prediction strategy. Model performance was assessed in terms of discrimination and calibration.
Results
Data of 36 470 eligible participants were extracted from the data set. The number of participants who fell at least once was 4 778 (13.1%). The final prediction model included age, sex, history of falls, 2 medications, and 5 medical conditions. The model had a median area under the receiver operating curve of 0.705 (interquartile range 0.700–0.714).
Conclusions
Our prediction model to identify older people at high risk for falls achieved fair discrimination and had reasonable calibration. It can be applied in clinical practice as it relies on routinely collected variables and does not require mobility assessment tests.
Summary This paper is based on a panel discussion held at the Artificial Intelligence in Medicine Europe (AIME) conference in Amsterdam, The Netherlands, in July 2007. It had been more than 15 years ...since Edward Shortliffe gave a talk at AIME in which he characterized artificial intelligence (AI) in medicine as being in its “adolescence” (Shortliffe EH. The adolescence of AI in medicine: will the field come of age in the ‘90s? Artificial Intelligence in Medicine 1993;5:93–106). In this article, the discussants reflect on medical AI research during the subsequent years and characterize the maturity and influence that has been achieved to date. Participants focus on their personal areas of expertise, ranging from clinical decision-making, reasoning under uncertainty, and knowledge representation to systems integration, translational bioinformatics, and cognitive issues in both the modeling of expertise and the creation of acceptable systems.
Inappropriate medication prescription is a common cause of preventable adverse drug events among elderly persons in the primary care setting.
The aim of this systematic review is to quantify the ...extent of inappropriate prescription to elderly persons in the primary care setting.
We systematically searched Ovid-Medline and Ovid-EMBASE from 1950 and 1980 respectively to March 2012. Two independent reviewers screened and selected primary studies published in English that measured (in)appropriate medication prescription among elderly persons (>65 years) in the primary care setting. We extracted data sources, instruments for assessing medication prescription appropriateness, and the rate of inappropriate medication prescriptions. We grouped the reported individual medications according to the Anatomical Therapeutic and Chemical (ATC) classification and compared the median rate of inappropriate medication prescription and its range within each therapeutic class.
We included 19 studies, 14 of which used the Beers criteria as the instrument for assessing appropriateness of prescriptions. The median rate of inappropriate medication prescriptions (IMP) was 20.5% IQR 18.1 to 25.6%.. Medications with largest median rate of inappropriate medication prescriptions were propoxyphene 4.52 (0.10-23.30)%, doxazosin 3.96 (0.32 15.70)%, diphenhydramine 3.30 (0.02-4.40)% and amitriptiline 3.20 (0.05-20.5)% in a decreasing order of IMP rate. Available studies described unequal sets of medications and different measurement tools to estimate the overall prevalence of inappropriate prescription.
Approximately one in five prescriptions to elderly persons in primary care is inappropropriate despite the attention that has been directed to quality of prescription. Diphenhydramine and amitriptiline are the most common inappropriately prescribed medications with high risk adverse events while propoxyphene and doxazoxin are the most commonly prescribed medications with low risk adverse events. These medications are good candidates for being targeted for improvement e.g. by computerized clinical decision support.
Only few studies have assessed the preventive effect of the STOPP/START criteria on adverse events. We aim to quantify 1) the association between nonadherence to STOPP/START criteria and ...gastrointestinal bleedings, and 2) the association between exposure to the potentially harmful START-medications and gastrointestinal bleedings.
A retrospective cohort study using routinely collected data of patients aged ≥ 65 years from the electronic health records (EHR) of 49 general practitioners (GPs) in 6 GP practices, from 2007 to 2014. The database is maintained in the academic research network database (AHA) of Amsterdam UMC, the Netherlands.
Gastrointestinal bleedings were identified using ICPC codes and free text inspections. Three STOPP and six START criteria pertaining to gastrointestinal bleedings were selected. Cox proportional hazards regression with time-dependent covariate analysis was performed to assess the independent association between nonadherence to the STOPP/START criteria and gastrointestinal bleedings. The analysis was performed with all criteria as a composite outcome, as well as separately for the individual criteria.
Out of 26,576 participants, we identified 19,070 Potential Inappropriate Medications (PIM)/Potential Prescribing Omission (PPO) instances for 3,193 participants and 146 gastrointestinal bleedings in 143 participants. The hazard ratio for gastrointestinal bleedings of STOPP/STARTs, taken as composite outcome, was 5.45 (95% CI 3.62-8.21). When analysed separately, two out of nine STOPP/STARTs showed significant associations.
This study demonstrates a significant positive association between nonadherence to the STOPP/START criteria and gastrointestinal bleeding. We emphasize the importance of adherence to the relevant criteria for gastrointestinal bleeding, which may be endorsed by decision support systems.
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.
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.
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