Higher Risk Of Severe Morbidity Research Articles

Preeclampsia outcomes at delivery and race

Objective: The objective of this study was to assess how race is associated with adverse maternal outcomes in the setting of preeclampsia.Study design: This retrospective cohort study utilized the National (Nationwide) Inpatient Sample (NIS) from the Agency for Health care Research and Quality for the years 2012–2014. Women aged 15–54 with a diagnosis of preeclampsia were included. Race and ethnicity were categorized as non-Hispanic white, non-Hispanic black, Hispanic, Asian or Pacific Islander, Native American, other, and unknown. The overall risk for severe morbidity based on Centers for Disease Control and Prevention criteria was analyzed along with the risk for specific outcomes such as stroke, acute heart failure or pulmonary edema, eclampsia, and acute renal failure. The risk for severe morbidity was stratified by comorbid risk and compared by race. Log-linear regression models were created to assess risk for severe morbidity with risk ratios and associated 95% confidence intervals as measures of effect.Results: A total of 101,741 women with preeclampsia from 2012 to 2014 were included in this analysis. The risk for severe morbidity was significantly higher among non-Hispanic black women (9.8%) than non-Hispanic white, Hispanic, and all other women, respectively (6.1, 7.7, and 7.5%, respectively, p < .01). For non-Hispanic black compared to non-Hispanic white, Hispanic, and all other women, risk was higher for stroke (17.1 versus 6.5, 12.7, and 9.3 per 10,000 deliveries, respectively, p < .01) and pulmonary edema or heart failure (56.2 versus 32.7, 30.2, and 38.4 per 10,000 deliveries, respectively, p < .01). Non-Hispanic black women were also more likely than non-Hispanic white women to experience renal failure (136.4 versus 60.4 per 10,000 deliveries, p < .01). Adjusting for comorbidity, black women remained at higher risk for severe morbidity (p < .01). The risk for death was higher for black compared to non-black women (121.8 per 100,000 deliveries, 95% CI 69.7–212.9 versus 24.1 per 100,000 deliveries, 95% CI 14.6–39.8, respectively, p < .01)Conclusion: Black women were at higher risk for severe morbidity and mortality associated with preeclampsia.

Hospitalization Outcomes in Pneumocystis Pneumonia Inpatient Population: A Comparison between HIV and Non-HIV Patients.

ObjectiveTo evaluate the difference in hospitalization outcomes, including morbidity and mortality among patients admitted for Pneumocystis pneumonia (PCP) with human immunodeficiency virus (HIV) and non-HIV condition.MethodsA case-control study was done using the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) data. We identified PCP and HIV as the primary and secondary diagnosis using ICD-9-­CM diagnosis codes. We used the multinomial logistic regression model to generate odds ratios (OR).ResultsA total number of 1250 PCP patients were enrolled in this retrospective analysis. PCP patients with HIV had eight times higher odds of non-elective admission based on emergency condition (OR = 7.873, P < .001) compared to non-HIV patients. PCP patients with HIV had eight times higher odds of longer hospitalization of more than eight days (OR = 8.687, P < .001) compared to non-HIV patients. HIV patients with PCP had five times higher odds of severe morbidity or extreme loss of body function (OR = 5.277, P < .001). PCP patients with HIV had 22 times higher likelihood of in-hospital mortality (OR = 21.845, P < .001) compared to non-HIV patients.ConclusionPCP patients with HIV have a higher risk of severe morbidity and in-hospital mortality as compared to non-HIV patients. More attention needs to be paid to the elderly population that is at a higher risk of PCP with HIV. We need additional research and studies to direct the development of clinical care models for aiming early diagnosis and treatment of HIV in PCP patients.

Evolution of Therapeutic Antibodies, Influenza Virus Biology, Influenza, and Influenza Immunotherapy

This narrative review article summarizes past and current technologies for generating antibodies for passive immunization/immunotherapy. Contemporary DNA and protein technologies have facilitated the development of engineered therapeutic monoclonal antibodies in a variety of formats according to the required effector functions. Chimeric, humanized, and human monoclonal antibodies to antigenic/epitopic myriads with less immunogenicity than animal-derived antibodies in human recipients can be produced in vitro. Immunotherapy with ready-to-use antibodies has gained wide acceptance as a powerful treatment against both infectious and noninfectious diseases. Influenza, a highly contagious disease, precipitates annual epidemics and occasional pandemics, resulting in high health and economic burden worldwide. Currently available drugs are becoming less and less effective against this rapidly mutating virus. Alternative treatment strategies are needed, particularly for individuals at high risk for severe morbidity. In a setting where vaccines are not yet protective or available, human antibodies that are broadly effective against various influenza subtypes could be highly efficacious in lowering morbidity and mortality and controlling unprecedented epidemic/pandemic. Prototypes of human single-chain antibodies to several conserved proteins of influenza virus with no Fc portion (hence, no ADE effect in recipients) are available. These antibodies have high potential as a novel, safe, and effective anti-influenza agent.

Postpartum hemorrhage outcomes and race

How race is associated with adverse outcomesinthe setting of postpartum hemorrhage is not well characterized. The objective of this study was to assess how race is associated with adverse maternal outcomes in the setting of postpartum hemorrhage. This retrospective cohort study utilized the National (Nationwide) Inpatient Sample (NIS) from the Agency for Healthcare Research and Quality for the years 2012-2014. Women aged 15-54 years with a diagnosis of postpartum hemorrhage were included. Race and ethnicity were categorized as non-Hispanic white, non-Hispanic black, Hispanic, Asian or Pacific Islander, Native American, other, and unknown. Overall risk for severe morbidity based on Centers for Disease Control and Prevention criteria was analyzed along with risk for specific outcomes such as disseminated intravascular coagulation, hysterectomy, transfusion, and maternal death. Risk for severe morbidity was stratified by comorbid risk and compared byrace. Weights were applied to create population estimates. Log-linear regression models were created to assess risk for severe morbidity with risk ratios and associated 95% confidence intervals as measures of effect. A total of 360,370 women with postpartum hemorrhage from 2012 to 2014 were included in this analysis. Risk for severe morbidity was significantly higher among non-Hispanic black women (26.6%) than non-Hispanic white, Hispanic, or Asian or Pacific Islander women (20.7%, 22.5%, and 21.4%, respectively, P < .01). For non-Hispanic black compared with non-Hispanic white, Hispanic, and Asian or Pacific Islander women risk was higher for disseminated intravascular coagulation (8.4% vs 7.1%, 6.8%, and 6.8%, respectively, P < .01) and transfusion (19.4% vs 13.9%, 16.1%, and 15.8%, respectively, P < .01). Black women were also more likely than non-Hispanic white women to undergo hysterectomy (2.4% vs 1.9%, P<.01), although Asian or Pacific Islander women were at highest risk (2.9%). Adjusting for comorbidity, black women remained at higher risk for severe morbidity (P < .01). Risk for death for non-Hispanic black women was significantly higher than for nonblack women (121.8 per 100,000 deliveries, 95% confidence interval, 94.7-156.8 vs 24.1 per 100,000 deliveries, 95% confidence interval, 19.2-30.2, respectively, P < .01). Black women were at higher risk for severe morbidity and mortality associated with postpartum hemorrhage.

Class I histone deacetylase inhibition improves pancreatitis outcome by limiting leukocyte recruitment and acinar‐to‐ductal metaplasia

Pancreatitis is a common inflammation of the pancreas with rising incidence in many countries. Despite improvements in diagnostic techniques, the disease is associated with high risk of severe morbidity and mortality and there is an urgent need for new therapeutic interventions. In this study, we evaluated whether histone deacetylases (HDACs), key epigenetic regulators of gene transcription, are involved in the development of the disease. We analysed HDAC regulation during cerulein-induced acute, chronic and autoimmune pancreatitis using different transgenic mouse models. The functional relevance of class I HDACs was tested with the selective inhibitor MS-275 in vivo upon pancreatitis induction and in vitro in activated macrophages and primary acinar cell explants. HDAC expression and activity were up-regulated in a time-dependent manner following induction of pancreatitis, with the highest abundance observed for class I HDACs. Class I HDAC inhibition did not prevent the initial acinar cell damage. However, it effectively reduced the infiltration of inflammatory cells, including macrophages and T cells, in both acute and chronic phases of the disease, and directly disrupted macrophage activation. In addition, MS-275 treatment reduced DNA damage in acinar cells and limited acinar de-differentiation into acinar-to-ductal metaplasia in a cell-autonomous manner by impeding the EGF receptor signalling axis. These results demonstrate that class I HDACs are critically involved in the development of acute and chronic forms of pancreatitis and suggest that blockade of class I HDAC isoforms is a promising target to improve the outcome of the disease.

Do Hospitals With a Higher Level of Maternal Care Designation Have Better Obstetric Outcomes? [9L

INTRODUCTION: Hospital designation of maternal care levels has been suggested as a way to combat rising maternal morbidity and mortality by ensuring access to adequate facilities. Our objective is to evaluate whether women with conditions that place them at high risk of severe morbidity have better outcomes when cared for at hospitals with a higher maternal level-of-care designation (MLOCD). METHODS: We conducted a telephone survey of birth hospitals in nine states as identified in 2012 State Inpatient Databases. Based on responses, MLOCD were assigned following criteria in the SMFM-ACOG “Maternal Levels of Care” document. The primary outcome was the rate of severe maternal morbidity overall and among high-risk subgroups of patients (ie, placenta previa, pre-eclampsia/eclampsia). Associations between MLOCD and maternal morbidity were evaluated. Final multivariable models adjusted for potential confounders. RESULTS: Overall, 90 hospitals, accounting for over 135,000 births were categorized into one of four levels of care. High-risk medical conditions were more prevalent in Level 4 hospitals. The overall frequency of severe maternal morbidity was 1.9%, although the frequency was 8.5% among high-risk women. After adjustment, there was no significant association between the MLOCD and composite maternal outcome. CONCLUSION: No association between MLOCD and maternal morbidity was detected. However, level 4 hospitals have a higher proportion of patients with pre-existing comorbidities, and even multivariable adjustment may not account for potentially important confounding. Prospective designation of hospital level and evaluation with patient outcomes is necessary to truly determine the impact of MLOCD and regionalization on maternal outcomes.

Development of a systematic protocol to identify victims of non-accidental trauma.

Each year, nearly 1 million children in the USA are victims of non-accidental trauma (NAT). Missed diagnosis or poor case management often leads to repeat/escalation injury. Victims of recurrent NAT are at higher risk for severe morbidity and mortality resulting from abuse. The objective of this review is to describe the evolution and implementation of this tool and evaluate our institutional response to NAT prior to implementation. A systematic guideline for the evaluation of pediatric patients in which NAT is suspected or confirmed was developed and implemented at a level II pediatric trauma hospital. To understand the state of our institution prior to implementation of the guideline, a review of 117 confirmed NAT cases at our hospital over the prior 4 years was conducted. In the absence of a systematic management guideline, important and relevant social and family history red flags were often missing in the initial evaluation. Patients with perineal bruising experienced significantly higher mortality than patients without perineal bruising (27.3 vs. 5.7%; p = 0.03) and were significantly more likely to require surgery (45.5 vs. 14.2%; p = 0.02). Development and implementation of a standardized tool for the differentiation and diagnosis of NAT and creation of a structured electronic medical record note should improve the description and documentation of child abuse cases in a community hospital setting. A retrospective analysis demonstrated that in the absence of such a tool, management of NAT may be inconsistent or incomplete. Perineal injury is an especially ominous red flag finding.

Prevention of Hb Bart’s (γ4) Disease Associated with the – –THAI α0-Thalassemia Deletion in Mainland China

α-Thalassemia (α-thal) is a common inherited disease in southern China. The severest form is Hb Bart’s (γ4) disease, in which the affected fetuses almost always die in utero or shortly after birth, and the mothers are at high risk for severe morbidity. The most common type of α0-thalassemia (α0-thal) in southern China is Southeast Asian (– –SEA) deletion. Occasionally, Hb Bart’s disease, caused by a compound heterozygosity for the – –SEA and – –THAI α0-thal deletions, can also be encountered. In this study, we report our experience with the prevention of Hb Bart’s disease associated with the – –THAI α0-thal deletion. A total of 385 couples at risk for Hb Bart’s disease, including seven who tested positive for the – –SEA deletion in one partner and the – –THAI deletion in the other, were found. Different prenatal procedures were offered, depending on the gestational age at presentation. Sixty-six affected fetuses were diagnosed prenatally; among these, two cases of Hb Bart’s disease were compound heterozygotes for the – –SEA and – –THAI deletions. All affected pregnancies were terminated in time. We also presented a diagnostic protocol for identification of α0-thal trait that can reduce the number of samples for detection of the – –THAI deletion.

Social context of preterm delivery in France in 2011 and impact on short-term health outcomes: the EPIPAGE 2 cohort study.

Low socio-economic context increases the risk of preterm delivery and may affect short-term outcomes in children born preterm. We described the social context of preterm delivery in France in 2011 and compared it with the general population of deliveries over the same period. We also studied how social context influenced pregnancy and delivery characteristics in the preterm population, and how it affected mortality and short-term morbidity in liveborn preterm children (<35 weeks). We created an individual socio-economic vulnerability index, derived from multiple correspondence analysis based on maternal social information in the French National Perinatal Survey (NPS-2010). Weighted coordinates were applied to families from the EPIPAGE 2 study, a population-based cohort of preterm infants born in 2011, to quantify the infant's exposure to socio-economic vulnerability. Multivariable logistic models were used to relate the socio-economic context to pregnancy and delivery characteristics, and to assess its impact on short-term outcomes of the infants. Among mothers of preterm infants, gestational age decreased as socio-economic conditions worsened. In the most deprived group, women had more irregular pregnancy care, a higher prevalence of infection during pregnancy, and a lower rate of antenatal corticosteroid administration. The most deprived group was associated with a higher risk of severe morbidity for the preterm neonates. Our results emphasise the need for a large population-based surveillance system to identify the most deprived mothers, and to propose appropriate follow-up and care to these women and their infants in order to enhance long-term health.

Prenatal control of Hb Bart’s hydrops fetalis: a two-year experience at a mainland Chinese hospital

α-Thalassemia is a common inherited disease in southern China. The severest form is Hb Bart’s hydrops fetalis, in which the affected fetuses almost always die in utero or shortly after birth, and the mothers are at high risk for severe morbidity. Therefore, this condition should be controlled, especially prenatally. In this study, we reported on a two-year experience in prenatal control of Hb Bart’s hydrops fetalis at a mainland Chinese hospital. Totally, 573 pregnancies at risk for Hb Bart’s hydrops fetalis were referred and different prenatal procedures were offered depending on the gestational age at presentation. One hundred fifty-two affected fetuses were diagnosed prenatally; among these, only half presented in early gestation, and were terminated in time. Although our prenatal program has successfully prevented the birth of children with severe thalassemia, it does not show a satisfactory outcome, considering the gestational age when an affected pregnancy is terminated.

Surgery for infective native valve endocarditis

Aims: Patients suffering from infective native valve endocarditis (NVE) are still at high risk for severe morbidity and mortality. We report our experiences in surgical therapy over the past decade.

Clinical Characteristics of Pandemic Influenza A (H1N1) 2009 Pediatric Infection in Busan and Gyeongsangnam-do: One Institution

BackgroundThis study investigated the clinical characteristics and risk factors of the severity of pandemic influenza A (H1N1) 2009 infection in pediatric patients in Busan and Gyeongsangnam-do.MethodsCases of influenza A (H1N1) 2009 in patients under the age of 18 years, confirmed by reverse transcription polymerase chain reaction, at Pusan National University Hospital and Pusan National University Yangsan Hospital from the last week of August 2009 through the last week of February 2010 were retrospectively analyzed.ResultsOf the 3,777 confirmed cases of influenza A (H1N1) 2009, 2,200 (58.2%) were male and 1,577 (41.8%) were female. The average age of the patients was 8.4±4.8 years. The total cases peaked during 44th to 46th week. Most of the patients were in the 5- to 9-year-old age group. Oseltamivir was administered to 2,959 (78.3%) of the patients. 221 patients (5.9%) were hospitalized, age an average of 6.7±4.5 years. The average duration of hospitalization was 7.4±5.6 days. One hundred cases (45.2%) had pneumonia. Risk factors for hospitalization included male gender, <2 years of age, and underlying disease. Children with asthma were at very high risk of hospitalization, over 20 times the non-asthmatic children (odds ratio [OR], 21.684; confidence interval [CI], 13.295~39.791). Likewise the children with neurologic deficits faced a 16 times higher risk (OR, 15.738; CI, 7.961~31.111). Ten of the patients (4.5%) were admitted to the intensive care unit, and eight (3.6%) required mechanical ventilation.ConclusionOf the pediatric patients with pandemic influenza A (H1N1) 2009, most of the patients were in the 5- to 9-year-old age group. Risk factors for hospitalization included male gender, <2 years of age, and underlying disease. The most common complication was pneumonia. The very high risk of severe morbidity in children with asthma or neurologic disease shows the critical importance of targeted vaccine coverage, special awareness and swift care by both guardians and primary care providers.

Pediatric Patients with Chronic Kidney Disease-Mineral Bone Disorder

Chronic kidney disease-mineral bone disorder (CKD-MBD) is a systemic disorder of mineral and bone metabolism that has deleterious consequences on skeletal and cardiovascular health. Nowhere is the morbidity of this disorder more telling than in children. During childhood and adolescence, CKD-MBD may result in poor growth and skeletal deformities, while the mineral dysregulation can manifest in cardiovascular disease in early adulthood, a development that places the patients at high risk for severe morbidity and early mortality. Unfortunately, management of CKD-MBD has been less than satisfactory in children despite recent advances and is limited by the lack of evidence-based treatment guidelines. More positive are ongoing research efforts, such as the Chronic Kidney Disease in Children and the Cardiovascular Comorbidity in Children with CKD (4C) studies that are currently providing important insights which should help better elucidate the pathogenesis and progression of mineral dysregulation and its clinical impact in children. Data from these studies and others will undoubtedly also help formulate clinical trials and the generation of evidence-based therapeutic options designed to provide more effective management of CKD-MBD in the pediatric population.

Surgery in current therapy for infective endocarditis

The introduction of the Duke criteria and transesophageal echocardiography has improved early recognition of infective endocarditis but patients are still at high risk for severe morbidity or death. Whether an exclusively antibiotic regimen is superior to surgical intervention is subject to ongoing debate. Current guidelines indicate when surgery is the preferred treatment, but decisions are often based on physician preferences. Surgery has shown to decrease the risk of short-term mortality in patients who present with specific symptoms or microorganisms; nevertheless even then it often remains unclear when surgery should be performed. In this review we i) systematically reviewed the current literature comparing medical to surgical therapy to evaluate if surgery is the preferred option, ii) performed a meta-analysis of studies reporting propensity matched analyses, and iii), briefly summarized the current indications for surgery.

Predictive social factors in relation to preterm birth in a metropolitan region

Preterm birth is an important indicator of neonatal wellbeing. Infants born preterm are at higher risk for severe morbidity and mortality. Apart from medical risk factors, social factors are also associated with preterm birth. This study aims to provide knowledge on factors which have a predictive role in relation to preterm birth. Cross-sectional population study. The Brussels metropolitan region. Women who gave birth in the Brussels metropolitan region in 2004. In total, 8,586 birth registration forms were reviewed for this study. Associations between educational level, occupation, marital status, age, and origin with preterm birth (<37 weeks). After bivariate analyses, significant correlations were explored in a stepwise logistic regression model. Odds ratios (OR) were calculated for each of the significant characteristics in the final model. The risk of preterm birth was found to be associated with age, origin, and marital status. After controlling for confounding factors, the two most important social risk factors for preterm birth were being a teenage mother (OR 2.15, 95% CI: 1.31-3.53) or single mother (OR 1.49, 95% CI: 1.17-1.91). Being a teenage or single mother are important social risk factors for preterm birth. We hypothesize that the increased risk is related to prenatal care trajectories. To obtain a better understanding of preterm birth occurrences, further research should focus on mapping these trajectories and specifically targeting the most vulnerable groups.

A Survey of Pregnancies with Hb Bart's Disease in Mainland China

α-Thalassemia (α-thal) is a common inherited disease in southern China. The severest form is Hb Bart's disease, in which the affected individuals are lethal in utero or shortly after birth, and the pregnancies are at high risk for severe morbidity. A survey by us revealed a total of 68 cases of Hb Bart's disease during the past 7 years at a maternal hospital and none of these showed that a risk of thalassemia had been recognized prior to the development of hydrops fetalis. The number of cases of Hb Bart's disease did not vary significantly during the study period. This means that the prevention program for α-thal has not been efficient. More effort is needed to efficiently control this disease in our region.