Hospital admission for hyperemesis gravidarum: a nationwide study of occurrence, reoccurrence and risk factors among 8.2 million pregnancies

STUDY QUESTION: What are the maternal risk factors for hyperemesis gravidarum (HG) hospital admission, readmission and reoccurrence in a following pregnancy? SUMMARY ANSWER: Young age, less socioeconomic deprivation, nulliparity, Asian or Black ethnicity, female fetus, multiple pregnancy, history of HG in a previous pregnancy, thyroid and parathyroid dysfunction, hypercholesterolemia and Type 1 diabetes are all risk factors for HG. WHAT IS KNOWN ALREADY: Women with Black or Asian ethnicity, of young age, carrying multiple babies or singleton females, with Type 1 diabetes or with a history of HG were previously reported to be at higher risk of developing HG; however, most evidence is from small studies. Little is known about associations with other comorbidities and there is controversy over other risk factors such as parity. Estimates of HG prevalence vary and there is a little understanding of the risks of HG readmission in a current pregnancy and reoccurrence rates in subsequent pregnancies, all of which are needed for planning measures to reduce onset or worsening of the condition. STUDY DESIGN, SIZE, DURATION: We performed a population-based cohort study of pregnancies ending in live births and stillbirths using prospectively recorded secondary care records (Hospital Episode Statistics) from England. We analysed those computerized and anonymized clinical records from over 5.3 million women who had one or more pregnancies between 1997 and 2012. PARTICIPANTS/MATERIALS, SETTING, METHODS: We obtained 8 215 538 pregnancies from 5 329 101 women of reproductive age, with a total of 186 800 HG admissions occurring during 121 885 pregnancies. Multivariate logistic regression with generalized estimating equations was employed to estimate odds ratios (aOR) to assess sociodemographic, pregnancy and comorbidity risk factors for HG onset, HG readmission within a pregnancy and reoccurrence in a subsequent pregnancy. MAIN RESULTS AND THE ROLE OF CHANCE: Being younger, from a less socioeconomically deprived status, of Asian or Black ethnicity, carrying a female fetus or having a multiple pregnancy all significantly increased HG and readmission risk but only ethnicity increased reoccurrence. Comorbidities most strongly associated with HG were parathyroid dysfunction (aOR = 3.83, 95% confidence interval 2.28–6.44), hypercholesterolemia (aOR = 2.54, 1.88–3.44), Type 1 diabetes (aOR = 1.95, 1.82–2.09), and thyroid dysfunction (aOR = 1.85, 1.74–1.96). History of HG was the strongest independent risk factor (aOR = 4.74, 4.46–5.05). Women with higher parity had a lower risk of HG compared with nulliparous women (aOR = 0.90, 0.89–0.91), which was not explained by women with HG curtailing further pregnancies. LIMITATIONS, REASONS FOR CAUTION: Although this represents the largest population-based study worldwide on the topic, the results could have been biased by residual and unmeasured confounding considering that some potential important risk factors such as smoking, BMI or prenatal care could not be measured with these data. Underestimation of non-routinely screened comorbidities such as hypercholesterolemia or thyroid dysfunction could also be a cause of selection bias. WIDER IMPLICATIONS OF THE FINDINGS: The estimated prevalence of 1.5% from our study was similar to the average prevalence reported in the literature and the representativeness of our data has been validated by comparison to national statistics. Also the prevalence of comorbidities was mostly similar to other studies estimating these in the UK and other developed countries. Women with Black or Asian ethnicity, of young age, carrying multiple babies or singleton females, with Type 1 diabetes or with history of HG were confirmed to be at higher risk of HG with an unprecedented higher statistical power. We showed for the first time that socioeconomic status interacts with maternal age, that hypercholesterolemia is a potential risk factor for HG and that carrying multiple females increases risk of hyperemesis compared with multiple males. We also provided robust evidence for the association of parity with HG. Earlier recognition and management of symptoms via gynaecology day-case units or general practitioner services can inform prevention and control of consequent hospital admissions. STUDY FUNDING/COMPETING INTEREST(S): The work was founded by The Rosetrees Trust and the Stoneygate Trust. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. C.N.-P. reports personal fees from Sanofi Aventis, Warner Chilcott, Leo Pharma, UCB and Falk, outside the submitted work and she is one of the co-developers of the RCOG Green Top Guideline on HG; all other authors did not report any potential conflicts of interest

Assessment of discharge treatment prescribed to women admitted to hospital for hyperemesis gravidarum

Aims: Prescribing drug treatment for the management of hyperemesis gravidarum (HG), the most severe form of nausea and vomiting in pregnancy, remains controversial. Since most manufacturers do not recommend prescribing antiemetics during pregnancy, little is known regarding which treatments are most prevalent among pregnant patients. Here we report for the first time, evidence of actual treatments prescribed in English hospitals.Methods: A retrospective pregnancy cohort was constructed using anonymised electronic records in the Nottingham University Hospitals Trust system for all women who delivered between January 2010 and February 2015. For women admitted to hospital for HG, medications prescribed on discharge were described and variation by maternal characteristics was assessed. Compliance with local and national HG treatment guidelines was evaluated.Results: Of 33,567 pregnancies (among 30,439 women), the prevalence of HG was 1.7%. Among 530 HG admissions with records of discharge drugs, Cyclizine was the most frequently prescribed (almost 73% of admissions). Prochlorperazine and metoclopramide were prescribed mainly in combination with other drugs, however, ondansetron was more common than metoclopramide at discharge from first and subsequent admissions. Steroids were only prescribed following readmissions. Thiamine was most frequently prescribed following readmission while high dose of folic acid was prescribed equally after first or subsequent admissions. Prescribing showed little variation by maternal age, ethnicity, weight, socioeconomic deprivation, or comorbidities.Conclusion: Evidence that management of HG in terms of discharge medications mainly followed local and national recommendations provides reassurance within the health professional community. Wider documentation of drugs prescribed to women with HG is required to enable full assessment of whether optimal drug management is being achieved

Do working practices of cancer nurse specialists improve clinical outcomes? Retrospective cohort analysis from the English National Lung Cancer Audit

Background Cancer nurse specialists are advanced practitioners who offer continuity of care and expert support for people diagnosed with specific cancers. Health Education England's Cancer Workforce Plan prioritises expansion of cancer nurse specialist numbers by 2021 as part of the Cancer Taskforce Strategy for England. Objective To assess whether working practices of advanced practice specialist nurses are associated with clinical outcomes for people with lung cancer. Methods Adults with non-small cell lung cancer followed from 30 days post-diagnosis in English secondary care were obtained from the English National Lung Cancer Audit, 2007 to 2011. A national survey of lung cancer nurse specialists provided information on self-reported working practices. Mortality and unplanned admissions from 30 days to 12 months post diagnosis were respectively analysed using Cox and Poisson regression. Outcomes were assessed according to patients’ receipt of initial assessments by a lung cancer nurse specialist and according to trust-level reported working practices. Regression models were adjusted for individual sociodemographic and clinical characteristics, error adjusted for intracorrelations within regional cancer networks, and presented separately according to patients’ treatment pathways (surgery, chemotherapy, radiotherapy, or no anti-cancer therapy). Results Data for 108,115 people with lung cancer were analysed and associations with mortality and unplanned admissions were infrequent. Among people receiving only radiotherapy, however, the hazard for death was 17% lower among those who received an assessment by a lung cancer nurse specialist, compared with no assessment (hazard ratio = 0.83, 95% confidence interval 0.73–0.94; p = 0.003). The hazard was also lower among those receiving surgery (hazard ratio = 0.91, 0.84–0.99; p = 0.028). Among those receiving radiotherapy, nurse specialists’ reported confidence within multidisciplinary team settings was associated with a lower risk of death (hazard ratio = 0.88, 0.78–1.00; p = 0.049) and a lower rate of unplanned cancer-related admissions (incidence rate ratio = 0.83, 0.73–0.95; p = 0.007). Lung cancer nurse specialist assessments before/at diagnosis, were associated with a 5% lower rate of unplanned admissions, compared to when assessments occurred after diagnosis. Conclusion The contribution of nurse specialist working practices was occasionally associated with better outcomes for people with lung cancer. These were not limited to a single treatment pathway, but do indicate discrete relationships within pathways. Our study provides initial measures of overall lung cancer nurse specialist working practices at trusts, however, more detailed studies with longitudinal measurement of lung cancer nurse specialist-patient interaction are needed to better ascertain impacts on long-term patient outcomes. The findings highlight opportunities for potential improvement in effectiveness of service and care management

Two measures of systemic inflammation are positively associated with haemoglobin levels in adolescent girls living in rural India: A cross‐sectional study

ObjectiveThis study tested the hypothesis that systemic inflammation is inversely associated with haemoglobin levels in adolescent girls in India.MethodsThe study population consisted of adolescent girls aged between 10 and 19 years living in a remote rural region in Maharashtra State, India. Data were collected on anthropometric measures, and a venous blood sample taken and tested for Complete Blood Count and C‐reactive Protein (CRP).ResultsOf 679 individuals who were invited to the research site to participate, data were available from 401 participants giving a response rate of 59%. Median blood CRP was 1.26 mg/L (Range 0.00 to 26.33), and 167 (41.6%) participants had CRP level [less than] 1.0 mg/L. The mean haemoglobin was 12.24 g/dL (Standard deviation [SD] 1.51), and the mean total White Blood Cells (WBC) count was 9.02 x103/μL (SD 2.00). With each g/dL increase in blood haemoglobin, the risk of having an elevated CRP of ≥1 mg/L increased with an odds ratio of 1.16 (95% CI 1.01 to 1.33, p=0.03). Total WBC count was also positively associated with blood haemoglobin, increasing by 0.24 x103/μL (95% CI 0.11 to 0.37, p [less than] 0.001) per g/dL increase in haemoglobin. Both analyses were adjusted for age. ConclusionsIn this population, blood haemoglobin levels were positively associated with two measures of systemic inflammation, contrary to the primary hypothesis being tested. Other unmeasured environmental exposures may modify haemoglobin levels in this population. Understanding this observation may help design better public health interventions to improve the wellbeing of adolescent girls in India

Prevalence of iron deficiency anaemia and risk factors in 1,010 adolescent girls from rural Maharashtra, India: a cross-sectional survey

Objective: Iron deficiency anaemia (IDA) is the most common nutritional disorder observed in adolescent girls in India. Our aim was to investigate the prevalence and risk factors associated with IDA in rural Maharashtra, India to address current evidence gaps. Study Design: Cross sectional survey Methods: The study recruited 13 to 17 year old adolescent girls living in 34 villages of Osmanabad district. Data were collected on individual health, dietary, sociodemographic factors, and anthropometric measurements were taken. Haemoglobin (Hb) levels were measured using Sahli’s hemometer. Logistic and linear regressions were used to identify risk factors associated with IDA and Hb level respectively. Results: Among 1,010 adolescent girls (response rate 97.5%), the mean Hb was 10.1 g/dl (standard deviation=1.3), and 87% had anaemia (Hb<12 g/dl). The prevalence of mild (11.0-11.9 g/dl), moderate (8.0-10.9 g/dl) and severe (Hb≤ 7.9 g/dl) anaemia was 17%, 65% and 5% respectively. Anaemia likelihood increased significantly with age (odds ratio (OR): 1.41 per year, 95% confidence interval (CI): 1.17 to 1.70). Factors associated with decreased anaemia risk were mid upper arm circumference (MUAC) ≥22 cm (OR: 0.51, 95% CI: 0.31 to 0.82), ≥3 days/week consumption of fruit (OR: 0.35, 95% CI: 0.23 to 0.54) or rice (OR: 0.39, 95% CI: 0.17 to 0.91), and incomplete schooling (OR: 0.47, 95% CI: 0.24 to 0.91). In the final model lower age, MUAC and fruit consumption were significantly associated with Hb level. Conclusion: Anaemia prevalence was extremely high among adolescent girls in rural areas of Maharashtra. Whilst we identified risk factors that could be used for targeting interventions, there is urgent need of comprehensive preventative interventions for the whole adolescent girl population

The Reach of the Fermilab Tevatron and CERN LHC for Gaugino Mediated SUSY Breaking Models

In supersymmetric models with gaugino mediated SUSY breaking (inoMSB), it is assumed that SUSY breaking on a hidden brane is communicated to the visible brane via gauge superfields which propagate in the bulk. This leads to GUT models where the common gaugino mass $m_{1/2}$ is the only soft SUSY breaking term to receive contributions at tree level. To obtain a viable phenomenology, it is assumed that the gaugino mass is induced at some scale $M_c$ beyond the GUT scale, and that additional renormalization group running takes place between $M_c$ and $M_{GUT}$ as in a SUSY GUT. We assume an SU(5) SUSY GUT above the GUT scale, and compute the SUSY particle spectrum expected in models with inoMSB. We use the Monte Carlo program ISAJET to simulate signals within the inoMSB model, and compute the SUSY reach including cuts and triggers approriate to Fermilab Tevatron and CERN LHC experiments. We find no reach for SUSY by the Tevatron collider in the trilepton channel. %either with or without %identified tau leptons. At the CERN LHC, values of $m_{1/2}=1000$ (1160) GeV can be probed with 10 (100) fb$^{-1}$ of integrated luminosity, corresponding to a reach in terms of $m_{\tg}$ of 2150 (2500) GeV. The inoMSB model and mSUGRA can likely only be differentiated at a linear $e^+e^-$ collider with sufficient energy to produce sleptons and charginos.Comment: 17 page revtex file with 9 PS figure

Probing Minimal Supergravity at the CERN LHC for Large tan⁡β\tan\beta

For large values of the minimal supergravity model parameter $\tan\beta$, the tau lepton and the bottom quark Yukawa couplings become large, leading to reduced masses of $\tau$-sleptons and $b$-squarks relative to their first and second generation counterparts, and to enhanced decays of charginos and neutralinos to $\tau$-leptons and $b$-quarks. We evaluate the reach of the CERN LHC $pp$ collider for supersymmetry in the mSUGRA model parameter space. We find that values of $m_{\tg}\sim 1500-2000$ GeV can be probed with just 10 fb$^{-1}$ of integrated luminosity for $\tan\beta$ values as high as 45, so that mSUGRA cannot escape the scrutiny of LHC experiments by virtue of having a large value of $\tan\beta$. We also perform a case study of an mSUGRA model at $\tan\beta =45$ where \tz_2\to \tau\ttau_1 and \tw_1\to \ttau_1\nu_\tau with $\sim 100$ branching fraction. In this case, at least within our simplistic study, we show that a di-tau mass edge, which determines the value of m_{\tz_2}-m_{\tz_1}, can still be reconstructed. This information can be used as a starting point for reconstructing SUSY cascade decays on an event-by-event basis, and can provide a strong constraint in determining the underlying model parameters. Finally, we show that for large $\tan\beta$ there can be an observable excess of $\tau$ leptons, and argue that $\tau$ signals might serve to provide new information about the underlying model framework.Comment: 22 page REVTEX file including 8 figure

Reach of the Fermilab Tevatron for minimal supergravity in the region of large scalar masses

The reach of the Fermilab Tevatron for supersymmetric matter has been calculated in the framework of the minimal supergravity model in the clean trilepton channel. Previous analyses of this channel were restricted to scalar masses m_0<= 1 TeV. We extend the analysis to large values of scalar masses m_0\sim 3.5 TeV. This includes the compelling hyperbolic branch/focus point (HB/FP) region, where the superpotential \mu parameter becomes small. In this region, assuming a 5\sigma (3\sigma) signal with 10 (25) fb^{-1} of integrated luminosity, the Tevatron reach in the trilepton channel extends up to m_{1/2}\sim 190 (270) GeV independent of \tan\beta . This corresponds to a reach in terms of the gluino mass of m_{\tg}\sim 575 (750) GeV.Comment: 11 page latex file including 6 EPS figures; several typos corrected and references adde

Higgs-mediated leptonic decays of B_s and B_d mesons as probes of supersymmetry

If tan(beta) is large, down-type quark mass matrices and Yukawa couplings cannot be simultaneously diagonalized, and flavour violating couplings of the neutral Higgs bosons are induced at the 1-loop level. These couplings lead to Higgs-mediated contributions to the decays B_s -> mu+ mu- and B_d -> tau+ tau-, at a level that might be of interest for the current Tevatron run, or possibly, at B-factories. We evaluate the branching ratios for these decays within the framework of minimal gravity-, gauge- and anomaly-mediated SUSY breaking models, and also in SU(5) supergravity models with non-universal gaugino mass parameters at the GUT scale. We find that the contribution from gluino loops, which seems to have been left out in recent phenomenological analyses, is significant. We explore how the branching fraction varies in these models, emphasizing parameter regions consistent with other observations.Comment: Revised to accommodate minor changes in original text and update reference

Linear Collider Capabilities for Supersymmetry in Dark Matter Allowed Regions of the mSUGRA Model

Recent comparisons of minimal supergravity (mSUGRA) model predictions with WMAP measurements of the neutralino relic density point to preferred regions of model parameter space. We investigate the reach of linear colliders (LC) with $\sqrt{s}=0.5$ and 1 TeV for SUSY in the framework of the mSUGRA model. We find that LCs can cover the entire stau co-annihilation region provided \tan\beta \alt 30. In the hyperbolic branch/focus point (HB/FP) region of parameter space, specialized cuts are suggested to increase the reach in this important ``dark matter allowed'' area. In the case of the HB/FP region, the reach of a LC extends well past the reach of the CERN LHC. We examine a case study in the HB/FP region, and show that the MSSM parameters $\mu$ and $M_2$ can be sufficiently well-measured to demonstrate that one would indeed be in the HB/FP region, where the lightest chargino and neutralino have a substantial higgsino component.Comment: 29 pages, 15 EPS figures; updated version slightly modified to conform with published versio