Editorial Board

Objective: The internally validated fulIPIERS model predicts adverse maternal outcomes in women with pre-eclampsia within 48 h after eligibility. Our objective was to assess generalizability of this prediction model. Study design: External validation study using prospectively collected data from two tertiary care obstetric centers. Methods: The existing PETRA dataset, a cohort of women (n = 216) with severe early-onset pre-eclampsia, eclampsia, HELLP syndrome or hypertension-associated fetal growth restriction was used. The fulIPIERS model equation was applied to all women in the dataset using values collected within 48 h after inclusion. The performance (ROC area and R-squared) of the model, risk stratification and calibration were assessed from 48 h up to a week after inclusion. Results: Of 216 women in the PETRA trial, 73 (34%) experienced an adverse maternal outcome(s) at any time after inclusion. Adverse maternal outcome was observed in 32 (15%) cases within 48 h and 62 (29%) within 7 days after inclusion. The fulIPIERS model predicted adverse maternal outcomes within 48 h (AUC ROC 0.97, 95% CI: 0.87-0.99) and up to 7 days after inclusion (AUC ROC 0.80, 95% CI: 0.70-0.87). Conclusions: The fullPIERS model performed well when applied to the PETRA dataset. These results confirm the usability of the fulIPIERS prediction model as a 'rule-in' test for women admitted with severe pre-eclampsia, eclampsia, HELLP syndrome or hypertension-associated fetal growth restriction. Future research should focus on intervention studies that assess the clinical impact of strategies using the fullPIERS model. (C) 2014 Elsevier Ireland Ltd. All rights reserved

Prediction of complications in early-onset pre-eclampsia (PREP): development and external multinational validation of prognostic models.

BACKGROUND: Unexpected clinical deterioration before 34 weeks gestation is an undesired course in early-onset pre-eclampsia. To safely prolong preterm gestation, accurate and timely prediction of complications is required. METHOD: Women with confirmed early onset pre-eclampsia were recruited from 53 maternity units in the UK to a large prospective cohort study (PREP-946) for development of prognostic models for the overall risk of experiencing a complication using logistic regression (PREP-L), and for predicting the time to adverse maternal outcome using a survival model (PREP-S). External validation of the models were carried out in a multinational cohort (PIERS-634) and another cohort from the Netherlands (PETRA-216). Main outcome measures were C-statistics to summarise discrimination of the models and calibration plots and calibration slopes. RESULTS: A total of 169 mothers (18%) in the PREP dataset had adverse outcomes by 48 hours, and 633 (67%) by discharge. The C-statistics of the models for predicting complications by 48 hours and by discharge were 0.84 (95% CI, 0.81-0.87; PREP-S) and 0.82 (0.80-0.84; PREP-L), respectively. The PREP-S model included maternal age, gestation, medical history, systolic blood pressure, deep tendon reflexes, urine protein creatinine ratio, platelets, serum alanine amino transaminase, urea, creatinine, oxygen saturation and treatment with antihypertensives or magnesium sulfate. The PREP-L model included the above except deep tendon reflexes, serum alanine amino transaminase and creatinine. On validation in the external PIERS dataset, the reduced PREP-S model showed reasonable calibration (slope 0.80) and discrimination (C-statistic 0.75) for predicting adverse outcome by 48 hours. Reduced PREP-L model showed excellent calibration (slope: 0.93 PIERS, 0.90 PETRA) and discrimination (0.81 PIERS, 0.75 PETRA) for predicting risk by discharge in the two external datasets. CONCLUSIONS: PREP models can be used to obtain predictions of adverse maternal outcome risk, including early preterm delivery, by 48 hours (PREP-S) and by discharge (PREP-L), in women with early onset pre-eclampsia in the context of current care. They have a potential role in triaging high-risk mothers who may need transfer to tertiary units for intensive maternal and neonatal care. TRIAL REGISTRATION: ISRCTN40384046 , retrospectively registered

Early intervention with inhaled corticosteroids in subjects with rapid decline in lung function and signs of bronchial hyperresponsiveness: results from the DIMCA programme.

Contains fulltext : 51862.pdf (publisher's version ) (Open Access)BACKGROUND: Asthma is generally accepted as an inflammatory disease that needs steroid treatment. However, when to start with inhaled steroids remains unclear. A study was undertaken to determine when inhaled corticosteroids should be introduced as the first treatment step. OBJECTIVE: To investigate the effectiveness of early introduction of inhaled steroids on decline in lung function in steroid-naive subjects with a rapid decline in lung function in general practice. SUBJECTS: Patients with signs/symptoms suspect of asthma (i.e., persistent and/or recurrent respiratory symptoms) and a decline in forced expiratory volume in 1 s (FEV(1)) during 1-year monitoring of 0.080 l or more and reversible obstruction (> or =10% predicted) or bronchial hyperresponsiveness (PC(20)< or =8 mg/ml) were studied. They had been identified in a population screening aiming to detect subjects at risk for chronic obstructive pulmonary disease (COPD) or asthma. DESIGN: A placebo-controlled, randomized, double-blind study. METHODS: 75 subjects out of a random population of 1155 were found eligible, and 45 were willingly to participate. Subjects were randomly treated with placebo or fluticasone propionate 250 microg b.i.d., and FEV(1) and PC(20) were monitored over a 2-year period. OUTCOME VARIABLES: The primary outcome measure was decline in FEV(1); the secondary outcome measure was bronchial hyperresponsiveness (PC(20)). RESULTS: 22 subjects were randomly allocated to the active group with inhaled corticosteroids and 23 to placebo. Change of FEV(1) in the active treated group was +43 ml in post-bronchodilator FEV(1) (p =0.341) and +62 ml/year (p =0.237) in pre-bronchodilator FEV(1) after 1 year, and -22 ml (p =0.304) for post-bronchodilator FEV(1) and -9.4 ml (p =0.691) for pre-bronchodilator FEV(1) after 2 years, compared to placebo. The effect on PC(20) was almost one dose-step (p =0.627) after 1 year and one dose-step (p =0.989) after 2 years. CONCLUSION: In this study, the early introduction of inhaled corticosteroids in newly diagnosed asthmatic subjects with rapid decline in lung function did not prove to be either clinically relevant or statistically significant in reversing the decline in FEV(1). For PC(20), no significant changes were detected

Impact of laser power and firing angle on coagulation efficiency in laser treatment for twin-twin transfusion syndrome:an ex vivo placenta study

\u3cp\u3eObjective: To assess the impact of laser power and firing angle on coagulation efficiency for closing placental anastomoses in the treatment of twin-twin transfusion syndrome. Methods: We used an ex vivo blood-perfused human placenta model to compare time to complete coagulation using 30 vs. 50 W of neodymium-doped yttrium aluminum garnet laser power and using a firing angle of 90° vs. 45°. Placentas were perfused with pig blood at 5 mL/min. Differences were analyzed using independent-samples t test, Mann-Whitney U test, or χ\u3csup\u3e2\u3c/sup\u3e test as appropriate. Results: Coagulation took less time and energy using 50 W (n = 53) compared to 30 W (n = 52), 11 vs. 22 s (p &lt; 0.001), and 557 vs. 659 J (p = 0.007). Perpendicular coagulation (n = 53) took less time and energy compared to a 45° angle (n = 21), 11 vs. 17 s (p = 0.004), and 557 vs. 871 J (p = 0.004). Bleeding complicated 2 (3%) measurements in the 50-W group, 5 (10%) in the 30-W group, and 3 (14%) in the 45° group. Discussion: In a highly controlled model, a 50-W laser power setting was more energy efficient than 30 W in coagulating a placental vein. A more perpendicular laser firing angle resulted in more efficient coagulation. Furthermore, bleeding due to vessel wall disruption occurred more often with lower power and a more tangential approach.\u3c/p\u3

Additional file 3: of Reduced rate of intensive care unit acquired gram-negative bacilli after removal of sinks and introduction of ‘water-free’ patient care

Colonization with Gram-negative bacilli. (DOCX 28 kb

Reduction of Gastrointestinal Bleeding in Patients with Heyde Syndrome Undergoing Transcatheter Aortic Valve Implantation

Background: Heyde syndrome is the co-occurrence of aortic stenosis and gastrointestinal bleeding secondary to angiodysplasias. Surgical aortic valve replacement effectively reduces bleeding, but the effects of transcatheter aortic valve implantation (TAVI) are largely unknown. This study aimed to describe the reduction of gastrointestinal bleeding in patients with Heyde syndrome after TAVI and to identify the factors associated with rebleeding. Methods: We enrolled patients with Heyde syndrome from a prospective TAVI registry. Gastrointestinal bleeding episodes were assessed by the Bleeding Academic Research Consortium classification, and cumulative incidence functions were used to calculate cessation rates. Factors potentially associated with rebleeding were analyzed using logistic regression. Differences between Heyde and non-Heyde patients were assessed through a case-cohort study. Results: Between December 2008 and June 2020, 1111 patients underwent TAVI. There were 70 patients with Heyde syndrome (6.3%). In the first year following TAVI, gastrointestinal bleeding ceased in 46 of 70 patients (62% [95% CI, 50%-74%]). Bleeding episodes decreased from 3.2 (95% CI, 2.5-4.2) to 1.6 ([95% CI, 1.2-2.2] P=0.001) and hemoglobin levels increased from 10.3 (95% CI, 10.0-10.8) to 11.3 (95% CI, 10.8-11.6) g/dL (P=0.007). Between 1 and 5 years after TAVI (35 [interquartile range, 21-51] months), 53 of 62 patients (83% [95% CI, 72%-92%]) no longer experienced gastrointestinal bleeding. Paravalvular leakage (≥mild) was associated with rebleeding risk (odds ratio, 3.65 [95% CI, 1.36-9.80]; P=0.010). Periprocedural bleeding was more common in Heyde than in control patients (adjusted odds ratio, 2.55 [95% CI, 1.37-4.73]; P=0.003). Conclusions: Patients with Heyde syndrome are at increased risk for periprocedural bleeding. Post-TAVI, gastrointestinal bleeding disappears in the majority of patients. Paravalvular leakage may curtail these clinical benefits