External validation of prognostic models for preeclampsia in a Dutch multicenter prospective cohort

Objective: To perform an external validation of all published prognostic models for first-trimester prediction of the risk of developing preeclampsia (PE). Methods: Women <14 weeks of pregnancy were recruited in the Netherlands. All systematically identified prognostic models for PE that contained predictors commonly available were eligible for external validation. Results: 3,736 women were included; 87 (2.3%) developed PE. Calibration was poor due to overestimation. Discrimination of 9 models for LO-PE ranged from 0.58 to 0.71 and of 9 models for all PE from 0.55 to 0.75. Conclusion: Only a few easily applicable prognostic models for all PE showed discrimination above 0.70, which is considered an acceptable performance

Effects of tocolysis with nifedipine or atosiban on child outcome: follow‐up of the APOSTEL III trial

Objective To compare the long‐term effects of tocolysis with nifedipine or atosiban on child outcome at age 2.5–5.5 years. Design The APOSTEL III trial was a multicentre randomised controlled trial that compared tocolysis with nifedipine or atosiban in 503 women with threatened preterm birth. Neonatal outcomes did not differ between both treatment arms, except for a higher incidence of intubation in the atosiban group. Methods Parents were asked to complete four questionnaires regarding neurodevelopment, executive function, behaviour problems and general health. Main outcome measures The main long‐term outcome measure was a composite of abnormal development at the age of 2.5–5.5 years. Results Of the 426 women eligible for follow‐up, 196 (46%) parents returned the questionnaires for 115 children in the nifedipine group and 110 children in the atosiban group. Abnormal development occurred in 32 children (30%) in the nifedipine group and in 38 children (38%) in the atosiban group (OR 0.74, 95% CI 0.41–1.34). The separate outcomes for neurodevelopment, executive function, behaviour, and general health showed no significant differences between the groups. Sensitivity analysis for all children of the APOSTEL III trial, including a comparison of deceased children, resulted in a higher rate of healthy survival in the nifedipine group (64 versus 54%), but there was no significant difference in the overall mortality rate (5.4 versus 2.7%). There were no significant subgroup effects. Conclusion Outcomes on broad child neurodevelopment, executive function, behaviour and general health were comparable in both groups. Neither nifedipine nor atosiban can be considered as the preferred treatment for women with threatened preterm birth. Tweetable abstract Nifedipine‐ and atosiban‐exposed children had comparable long‐term outcomes, including neurodevelopment, executive function and behaviour

Prognostic models versus single risk factor approach in first‐trimester selective screening for gestational diabetes mellitus: a prospective population‐based multicentre cohort study

Objectives: To evaluate whether (1) first-trimester prognostic models for gestational diabetes mellitus (GDM) outperform the currently used single risk factor approach, and (2) a first-trimester random venous glucose measurement improves model performance. Design: Prospective population-based multicentre cohort. Setting: Thirty-one independent midwifery practices and six hospitals in the Netherlands. Population: Women recruited before 14 weeks of gestation without pre-existing diabetes. Methods: The single risk factor approach (presence of at least one risk factor: BMI ≥30 kg/m2, previous macrosomia, history of GDM, positive first-degree family history of diabetes, non-western ethnicity) was compared with the four best performing models in our previously published external validation study (Gabbay-Benziv 2014, Nanda 2011, Teede 2011, van Leeuwen 2010) with and without the addition of glucose. Main outcome measures: Discrimination was assessed by c-statistics, calibration by calibration plots, added value of glucose by the likelihood ratio chi-square test, net benefit by decision curve analysis and reclassification by reclassification plots. Results: Of the 3723 women included, a total of 181 (4.9%) developed GDM. The c-statistics of the prognostic models were higher, ranging from 0.74 to 0.78 without glucose and from 0.78 to 0.80 with glucose, compared with the single risk factor approach (0.72). Models showed adequate calibration, and yielded a higher net benefit than the single risk factor approach for most threshold probabilities. Teede 2011 performed best in the reclassification analysis. Conclusions: First-trimester prognostic models seem to outperform the currently used single risk factor approach in screening for GDM, particularly when glucose was added as a predictor. Tweetable abstract: Prognostic models seem to outperform the currently used single risk factor approach in screening for gestational diabetes

Effects of tocolysis with nifedipine or atosiban on child outcome:follow-up of the APOSTEL III trial

Objective: To compare the long-term effects of tocolysis with nifedipine or atosiban on child outcome at age 2.5–5.5 years. Design: The APOSTEL III trial was a multicentre randomised controlled trial that compared tocolysis with nifedipine or atosiban in 503 women with threatened preterm birth. Neonatal outcomes did not differ between both treatment arms, except for a higher incidence of intubation in the atosiban group. Methods: Parents were asked to complete four questionnaires regarding neurodevelopment, executive function, behaviour problems and general health. Main outcome measures: The main long-term outcome measure was a composite of abnormal development at the age of 2.5–5.5 years. Results: Of the 426 women eligible for follow-up, 196 (46%) parents returned the questionnaires for 115 children in the nifedipine group and 110 children in the atosiban group. Abnormal development occurred in 32 children (30%) in the nifedipine group and in 38 children (38%) in the atosiban group (OR 0.74, 95% CI 0.41–1.34). The separate outcomes for neurodevelopment, executive function, behaviour, and general health showed no significant differences between the groups. Sensitivity analysis for all children of the APOSTEL III trial, including a comparison of deceased children, resulted in a higher rate of healthy survival in the nifedipine group (64 versus 54%), but there was no significant difference in the overall mortality rate (5.4 versus 2.7%). There were no significant subgroup effects. Conclusion: Outcomes on broad child neurodevelopment, executive function, behaviour and general health were comparable in both groups. Neither nifedipine nor atosiban can be considered as the preferred treatment for women with threatened preterm birth. Tweetable abstract: Nifedipine- and atosiban-exposed children had comparable long-term outcomes, including neurodevelopment, executive function and behaviour

Effects of tocolysis with nifedipine or atosiban on child outcome: follow‐up of the APOSTEL III trial

Objective To compare the long‐term effects of tocolysis with nifedipine or atosiban on child outcome at age 2.5–5.5 years. Design The APOSTEL III trial was a multicentre randomised controlled trial that compared tocolysis with nifedipine or atosiban in 503 women with threatened preterm birth. Neonatal outcomes did not differ between both treatment arms, except for a higher incidence of intubation in the atosiban group. Methods Parents were asked to complete four questionnaires regarding neurodevelopment, executive function, behaviour problems and general health. Main outcome measures The main long‐term outcome measure was a composite of abnormal development at the age of 2.5–5.5 years. Results Of the 426 women eligible for follow‐up, 196 (46%) parents returned the questionnaires for 115 children in the nifedipine group and 110 children in the atosiban group. Abnormal development occurred in 32 children (30%) in the nifedipine group and in 38 children (38%) in the atosiban group (OR 0.74, 95% CI 0.41–1.34). The separate outcomes for neurodevelopment, executive function, behaviour, and general health showed no significant differences between the groups. Sensitivity analysis for all children of the APOSTEL III trial, including a comparison of deceased children, resulted in a higher rate of healthy survival in the nifedipine group (64 versus 54%), but there was no significant difference in the overall mortality rate (5.4 versus 2.7%). There were no significant subgroup effects. Conclusion Outcomes on broad child neurodevelopment, executive function, behaviour and general health were comparable in both groups. Neither nifedipine nor atosiban can be considered as the preferred treatment for women with threatened preterm birth. Tweetable abstract Nifedipine‐ and atosiban‐exposed children had comparable long‐term outcomes, including neurodevelopment, executive function and behaviour

External validation of prognostic models to predict risk of gestational diabetes mellitus in one Dutch cohort: prospective multicentre cohort study

OBJECTIVE To perform an external validation and direct comparison of published prognostic models for early prediction of the risk of gestational diabetes mellitus, including predictors applicable in the first trimester of pregnancy. DESIGN External validation of all published prognostic models in large scale, prospective, multicentre cohort study. SETTING 31 independent midwifery practices and six hospitals in the Netherlands. PARTICIPANTS Women recruited in their first trimester (<14 weeks) of pregnancy between December 2012 and January 2014, at their initial prenatal visit. Women with pre-existing diabetes mellitus of any type were excluded. MAIN OUTCOME MEASURES Discrimination of the prognostic models was assessed by the C statistic, and calibration assessed by calibration plots. RESULTS 3723 women were included for analysis, of whom 181 (4.9%) developed gestational diabetes mellitus in pregnancy. 12 prognostic models for the disorder could be validated in the cohort. C statistics ranged from 0.67 to 0.78. Calibration plots showed that eight of the 12 models were well calibrated. The four models with the highest C statistics included almost all of the following predictors: maternal age, maternal body mass index, history of gestational diabetes mellitus, ethnicity, and family history of diabetes. Prognostic models had a similar performance in a subgroup of nulliparous women only. Decision curve analysis showed that the use of these four models always had a positive net benefit. CONCLUSIONS In this external validation study, most of the published prognostic models for gestational diabetes mellitus show acceptable discrimination and calibration. The four models with the highest discriminative abilities in this study cohort, which also perform well in a subgroup of nulliparous women, are easy models to apply in clinical practice and therefore deserve further evaluation regarding their clinical impact

How accurate is the prehospital diagnosis of hyperventilation syndrome?

Background: The literature suggests that hyperventilation syndrome (HVS) should be diagnosed and treated prehospitally. Aim: To determine diagnostic accuracy of HVS by paramedics and emergency medical technicians using hospital doctors' diagnosis as the reference standard. Methods: A retrospective audit was carried out of routine data using linked prehospital and in-hospital patient records of adult patients (≥18 years) transported via emergency ambulance to two emergency departments in the UK from 1 January 2012–31 December 2013. Accuracy was measured using sensitivity, specificity, positive and negative predictive values (NPV/PPVs) and likelihood ratios (LRs) with 95% confidence intervals. Results: A total of 19 386 records were included in the analysis. Prehospital clinicians had a sensitivity of 88% (95% CI [82–92%]) and a specificity of 99% (95% CI [99–99%]) for diagnosing HVS, with PPV 0.42 (0.37, 0.47), NPV 1.00 (1.00, 1.00), LR+ 75.2 (65.3, 86.5) and LR− 0.12 (0.08, 0.18). Conclusions: Paramedics and emergency medical technicians are able to diagnose HVS prehospitally with almost perfect specificity and good sensitivity