Risk Of Several Adverse Outcomes Research Articles

Low Maternal Capital Predicts Life History Trade-Offs in Daughters: Why Adverse Outcomes Cluster in Individuals.

Background: Some individuals appear prone to multiple adverse outcomes, including poor health, school dropout, risky behavior and early reproduction. This clustering remains poorly understood. Drawing on evolutionary life history theory, we hypothesized that maternal investment in early life would predict the developmental trajectory and adult phenotype of female offspring. Specifically, we predicted that daughters receiving low investment would prioritize the life history functions of “reproduction” and “defense” over “growth” and “maintenance,” increasing the risk of several adverse outcomes.Methods: We investigated 2,091 mother-daughter dyads from a birth cohort in Pelotas, Brazil. We combined data on maternal height, body mass index, income, and education into a composite index of “maternal capital.” Daughter outcomes included reproductive status at 18 years, growth, adult anthropometry, body composition, cardio-metabolic risk, educational attainment, work status, and risky behavior. We tested whether daughters' early reproduction (<18 years) and exposure to low maternal capital were associated with adverse outcomes, and whether this accounted for the clustering of adverse outcomes within individuals.Results: Daughters reproducing early were shorter, more centrally adipose, had less education and demonstrated more risky behavior compared to those not reproducing. Low maternal capital was associated with greater likelihood of the daughter reproducing early, smoking and having committed violent crime. High maternal capital was positively associated with the daughter's birth weight and adult size, and the likelihood of being in school. Associations of maternal capital with cardio-metabolic risk were inconsistent. Daughters reproducing early comprised 14.8% of the population, but accounted for 18% of obesity; 20% of violent crime, low birth weight and short stature; 32% of current smoking; and 52% of school dropout. Exposure to low maternal capital contributed similarly to the clustering of adverse outcomes among daughters. Outcomes were worst among daughters characterized by both low maternal capital and early reproduction.Conclusion: Consistent with life history theory, daughters exposed to low maternal capital demonstrate “future discounting” in behavior and physiology, prioritizing early reproduction over growth, education, and health. Trade-offs associated with low maternal capital and early reproduction contribute to clustering of adverse outcomes. Our approach provides new insight into inter-generational cycles of disadvantage.

The laparoscopic approach to distal pancreatectomy is a value-added proposition for patients undergoing care in moderate-volume and high-volume centers

BackgroundLittle is known regarding the impact of the minimally invasive approach to distal pancreatectomy on the aggregate costs of care for patients undergoing distal pancreatectomy. MethodsWe queried the Healthcare Cost and Utilization Project State Inpatient Database to identify patients undergoing elective laparoscopic distal pancreatectomy or open distal pancreatectomy between 2012 and 2014. Multivariable regression was used to evaluate postoperative outcomes including readmissions to 90 days after distal pancreatectomy. ResultsA total of 267 (11%) patients underwent laparoscopic distal pancreatectomy, and a total of 2,214 (89%) underwent open distal pancreatectomy. On multivariable regression, patients undergoing laparoscopic distal pancreatectomy had a decreased odds risk of having any severe adverse outcome (odds ratio 0.73, 95% confidence interval [0.54–0.97]), prolonged length of stay (odds ratio 0.49, 95% confidence interval [0.30–0.79]), and of being in the highest quartile for aggregate costs of care (odds ratio 0.46, 95% confidence interval [0.32–0.66]) relative to those undergoing open distal pancreatectomy. Patients undergoing laparoscopic distal pancreatectomy had a lower average 90-day aggregate cost of care than those undergoing open distal pancreatectomy when procedures were performed in high-volume (–$16,153, 95% CI: [–$23,342 to –$8,964]) centers. ConclusionPatients undergoing laparoscopic distal pancreatectomy have a lower risk of severe adverse outcomes, prolonged overall length of stay, and lower associated costs of care relative to those undergoing open distal pancreatectomy. This association is independent of hospital volume.

Symptom Burden Among Community-Dwelling Older Adults in the United States.

To determine the prevalence and impact of common co-occurring symptoms among community-dwelling older adults in the United States. The National Health and Aging Trends Study is a nationally representative, prospective study with annual data collection between 2011 and 2017. Community-based, in-person interviews (survey response rates, 71%-96%). A total of 7,609 community-dwelling Medicare beneficiaries, 65 years or older. Symptoms assessed at baseline include pain, fatigue, breathing difficulty, sleeping difficulty, depressed mood, and anxiety. Total symptom count ranged from zero to six. Several outcomes were examined, including grip strength, gait speed, and overall lower-extremity function as well as incidence of recurrent falls (two or more per year), hospitalization, disability, nursing home admission, and mortality. Prevalence of zero, one, two, three, and four or more symptoms was 25.0%, 26.6%, 20.7%, 14.0%, and 13.6%, respectively. Symptom count increased with advancing age and was higher in women than in men. Pain and fatigue were the most common co-occurring symptoms. Higher symptom count was associated with decreased physical capacity. For example, participants with one, two, three, and four or more symptoms had gait speeds that were 0.04, 0.06, 0.09, and 0.13 m/s slower, respectively, than those with no symptoms, adjusting for specific diseases, total number of diseases, and other potential confounders (P < .001). The risk of several adverse outcomes also increased with greater symptom count. For example, compared with those with no symptoms, the adjusted risk ratios for recurrent falls were 1.48 (95% confidence interval [CI] = 1.30-1.70), 1.54 (95% CI = 1.32-1.80), 1.90 (95% CI = 1.55-2.32), and 2.38 (95% CI = 2.00-2.83) for older adults with one, two, three, and four or more symptoms, respectively. Symptoms frequently co-occur among community-dwelling older adults and are strongly associated with increased risk of a range of adverse outcomes. Symptoms represent a potential treatment target for improving outcomes and should be systematically captured in health records. J Am Geriatr Soc 67:223-231, 2019.

Food-induced fatal anaphylaxis: From epidemiological data to general prevention strategies.

Anaphylaxis hospitalizations are increasing in many countries, in particular for medication and food triggers in young children. Food-related anaphylaxis remains an uncommon cause of death, but a significant proportion of these are preventable. To review published epidemiological data relating to food-induced anaphylaxis and potential risk factors of fatal and/or near-fatal anaphylaxis cases, in order to provide strategies to reduce the risk of severe adverse outcomes in food anaphylaxis. We identified 32 published studies available in MEDLINE (1966-2017), EMBASE (1980-2017), CINAHL (1982-2017), using known terms and synonyms suggested by librarians and allergy specialists. Young adults with a history of asthma, previously known food allergy particularly to peanut/tree nuts are at higher risk of fatal anaphylaxis reactions. In some countries, cow's milk and seafood/fish are also becoming common triggers of fatal reactions. Delayed adrenaline injection is associated with fatal outcomes, but timely adrenaline alone may be insufficient. There is still a lack of evidence regarding the real impact of these risk factors and co-factors (medications and/or alcohol consumption, physical activities, and mast cell disorders). General strategies should include optimization of the classification and coding for anaphylaxis (new ICD 11 anaphylaxis codes), dissemination of international recommendations on the treatment of anaphylaxis, improvement of the prevention in food and catering areas, and dissemination of specific policies for allergic children in schools. Implementation of these strategies will involve national and international support for ongoing local efforts in relationship with networks of centres of excellence to provide personalized management (which might include immunotherapy) for the most at-risk patients.

Prevalence and clinical profiles of disproportionate and proportionate microcephaly in China: a population-based cross-sectional study

BackgroundGuangzhou is a large city with a climate that is conducive to transmission of the dengue virus, and it is also at high risk of a zika epidemic. Viral, bacterial, and parasitic infections can lead to microcephaly, but data on microcephaly in China are limited. This study aimed to estimate the prevalence of microcephaly and the clinical spectrum of disproportionate and proportionate microcephaly in Guangzhou, China. MethodsA prospective surveillance study of microcephaly at birth was conducted at four perinatal health-care centres from February 2017 to August 2017 in Guangzhou, China. The Intergrowth-21st head circumference (HC) curves were used as the reference. Microcephaly was defined as a HC of more than 3 SD below the mean for sex and gestational age. Based on the neonates' HCs and birth weights, the study group was subdivided into those with disproportionate microcephaly, proportionate microcephaly, or normocephaly. Poisson exact 95% CIs of the prevalence of microcephaly were estimated. Maternal characteristics (including infection) and neonatal characteristics were examined for differences between microcephaly and normocephaly, and the association of neonatal complications with disproportionate and proportionate microcephaly was assessed using Poisson regression, in comparison with equivalent data for normocephaly. FindingsA total of 19 854 births were included, of which 88 had microcephaly, giving a prevalence of 0·44% (95% CI 0·35%–0·55%). Compared to women who delivered a baby with normocephaly, women who delivered a baby with microcephaly were younger (mean 29·1 (SD 5·1) years vs 30·3 (4·7) years, p=0·0222), had a higher proportion of nulliparity (60·2% vs 40·5%, p=0·0002), a higher prevalence of gestational hypertension (8·0% vs 2·3%, p=0·0004), and a shorter gestation length (mean 37·2 (SD4·1) weeks vs 39·0 (1·6) weeks, p<0·0001). The rates of maternal and neonatal infectious and parasitic diseases were not significantly higher in microcephaly than in normocephaly. The prevalence of disproportionate and proportionate microcephaly was 0·10% (95% CI 0·058%–0·15%) and 0·35% (95% CI 0·27%–0·44%), respectively. The proportion of women who were carriers of viral hepatitis B was higher in disproportionate microcephaly than in normocephaly (42·9% vs 7·3%, p=0·0107), whereas in proportionate microcephaly it was comparable to normocephaly (15·2% vs 7·3%, p=0·0471). Disproportionate microcephaly was associated with a substantially higher risk of stillbirth (adjusted RR [aRR] 44·1, 95% CI 6·1, 317·5), an Apgar score of <7 at 1 min (60·1, 7·5, 481·0), fetal growth restriction (8·6, 1·6, 47·0), and hyperbilirubinemia (2·1, 1·2, 3·7), than normocephaly. The risk of congenital heart disease was higher in proportionate microcephaly than in normocephaly (2·9, 0·5, 15·7) but was not significantly higher in disproportionate microcephaly than normocephaly (3·1, 1·6, 6·3). InterpretationExtrapolated to the near 18 million annual births in China, there may be an estimated 79 200 microcephaly cases each year. Disproportionate microcephaly is associated with substantially higher risk of severe adverse outcomes. Maternal carrier of viral hepatitis B is identified as a new risk factor for disproportionate microcephaly, but the mechanism is unclear and should be studied further. FundingThe National Natural Science Foundation of China (numbers 81673181 and 81703244), the National Key Research and Development Program of China (numbers 2016YFC1000205 and 2016YFC1000304), the European Union Horizon 2020 Research and Innovation Programme under ZIKAlliance (number 73458), and the Laboratoire d'Excellence Integrative Biology of Emerging Infectious Diseases programme (number ANR-10-LABX-62-IBEID).

A Propensity Score Matched Comparison of Clinical Outcomes in Atrial Fibrillation Patients Taking Vitamin K Antagonists: Comparing the “Real-World” vs Clinical Trials

ObjectiveTo investigate the incidence and risk of adverse clinical outcomes in a “real-world” cohort of patients with atrial fibrillation (AF) anticoagulated with vitamin K antagonists (VKAs) from the Murcia AF Project in comparison with the warfarin arm of the randomized clinical trial (RCT) AMADEUS (Evaluating the Use of SR34006 Compared to Warfarin or Acenocoumarol in Patients With Atrial Fibrillation). Patients and MethodsWe included 1361 patients with AF from the Murcia AF Project (recruitment from May 1, 2007, to December 1, 2007) and 2293 from the AMADEUS trial (started in September 2003 and primary completed in March 2006), all taking VKA treatment. After propensity score matching (PSM), we investigated differences in rates and risks of several events, including major bleeding, ischemic stroke, and all-cause mortality at 365 (interquartile range, 275-428) days of follow-up. ResultsAfter PSM there were 1324 patients for the comparative analysis, whereby annual event rates for most adverse events were significantly higher in the “real-world” population. Cox regression analyses demonstrated that the risk of primary outcomes was also increased in the “real-world” (vs RCT: hazard ratio [HR], 6.32; 95% CI, 2.84-14.03 for major bleeding; HR, 3.56, 95% CI, 1.22-10.42 for ischemic stroke; HR, 5.13, 95% CI, 3.02-8.69 for all-cause mortality). The risk of all other adverse events was higher in the real-world cohort, except for cardiovascular mortality. ConclusionThis study comparing the Murcia AF Project and the AMADEUS trial demonstrates that there is a great heterogeneity in both populations, which is translated into a higher risk of several adverse outcomes in the real-world cohort, including major bleeding, ischemic stroke, and mortality.

Risk factors for adverse maternal and perinatal outcomes in women with preeclampsia: analysis of 1396 cases.

Preeclampsia is a major cause of adverse maternal and perinatal outcomes, but how to identify women and fetuses at increased risk for later adverse events is a challenge. This study aimed to investigate the risk factors for adverse maternal and perinatal outcomes in women with preeclampsia. Data from 1396 women with preeclampsia were retrospectively collected and analyzed. Eighteen candidate risk factors and 12 adverse outcomes were investigated. The following factors were found to be significantly associated with at least one adverse outcome: maternal age 35 years or older, multiple birth, the usage of assisted reproductive technology, living in a rural area, history of pregnancy-induced hypertension, male fetus, multigravida, or having polycystic ovary syndrome, hemolysis, elevated liver enzymes, and low platelet count syndrome, intrahepatic cholestasis of pregnancy, cardiovascular disease, gestational diabetes mellitus, systemic lupus erythematosus, thyroid disease, or liver disease. Compared with patients without any identified risk factors, patients with preeclampsia with three or more risk factors were at increased risk for severe adverse outcomes. Those findings demonstrated that maternal risk factors could be used as indicators supplementary to clinical symptoms and laboratory test results for the risk assessment in women with preeclampsia.

Maternal and neonatal outcomes following abnormally invasive placenta: a population-based record linkage study.

Abnormally invasive placenta involves abnormal adherence of the placenta to the myometrium and is associated with severe pregnancy complications such as blood transfusion and hysterectomy. Knowledge of outcomes has been limited by small sample sizes and a focus on maternal rather than neonatal outcomes. This study uses population-level data collected over 10years to investigate maternal and neonatal outcomes and trends in incidence of abnormally invasive placenta (also known as placenta accreta, increta and percreta). A population-based record linkage study was performed, including all women who gave birth in New South Wales, Australia, between 2003 and 2012. Data were obtained from birth records, hospital admissions and deaths registrations. Modified Poisson regression models, adjusted for confounding factors, were used to quantify the effect of abnormally invasive placenta on adverse maternal and neonatal outcomes. Abnormally invasive placenta was significantly associated with morbidity for mothers (adjusted relative risk 17.6, 99% confidence interval 14.5-21.2) and infants (adjusted relative risk 3.1, 99% confidence interval 2.7-3.5). Abnormally invasive placenta increased risk of stillbirth (relative risk 5.4, 99% confidence interval 4.0-7.3) and neonatal death (relative risk 8.0, 99% confidence interval 1.5-41.6). The overall rate of abnormally invasive placenta was 24.8 per 10000 deliveries, and 22.7 per 10000 among primiparae. Incidence increased by 30%, from 20.6 to 26.9 per 10000, over the 10-year study period. Abnormally invasive placenta substantially increases the risk of severe adverse outcomes for mothers and babies, and the incidence is increasing. Delivery should occur in tertiary hospitals equipped with neonatal intensive care units. Clinicians should be cognizant of the risks, particularly to infants, and maintain a high index of suspicion of abnormally invasive placenta, including in primiparae.

Attitudes to Ageing and Change in Frailty Status: The English Longitudinal Study of Ageing

Background: Older people with more negative attitudes to ageing are at increased risk of several adverse outcomes, including decline in physical function and increased difficulties with activities of daily living. Objective: We investigated whether negative attitudes to ageing increase the risk of the onset or progression of frailty. Method: Participants were 3,505 men and women aged 60 years and over from the English Longitudinal Study of Ageing. They completed a 12-item questionnaire on attitudes to ageing. Exploratory factor analysis was used to examine the structure of these items, and a single factor was derived which we labelled “physical and psychological loss.” Frailty was assessed by the Fried phenotype of physical frailty at waves 2 and 4, and by a frailty index at waves 2-5. Results: Having a more positive attitude to ageing as regards “physical and psychological loss” was associated with a decreased risk of becoming physically frail or pre-frail at follow-up. For a standard deviation increment in score, the relative risk ratios (95% confidence interval), adjusted for age, sex and baseline level of physical frailty, were 0.86 (0.79, 0.94) for pre-frailty and 0.72 (0.63, 0.83) for frailty. Further adjustment for other potential confounding variables had only slight attenuating effects on these associations: multivariable-adjusted relative risk ratios were 0.89 (0.81, 0.98) for pre-frailty and 0.78 (0.68, 0.91) for frailty. Attitude to ageing was not associated with change in the frailty index over time after adjustment for potential confounding variables. Conclusion: Older people who have a more positive attitude to ageing are at reduced risk of becoming physically frail or pre-frail. Future research needs to replicate this finding and discover the underlying mechanisms. Attitude to ageing was not a risk factor for change in the more broadly defined frailty index.

An intermediate sFlt-1/PlGF ratio indicates an increased risk for adverse pregnancy outcome.

The sFlt-1/PlGF ratio is a valid marker in diagnosing or excluding preeclampsia. The currently used cut offs frame an intermediate zone of 33-85 (<340 weeks) or 33-110 (≥340 weeks), respectively. In this study we sought to evaluate the relevance of an intermediate sFlt-1/PlGF ratio for the clinical pregnancy course and outcome. We retrospectively analysed 533 consecutive patients with sFlt-1/PlGF ratio measurements for suspected preeclampsia. In patients with an intermediate sFlt-1/PlGF ratio, fetal and maternal characteristics and also pregnancy outcome were documented. Furthermore, we compared the patient groups with <340/340-366/≥370 gestational weeks at first visit. 83/533 (15.6%) patients had an intermediate sFlt-1/PlGF ratio. Maternal or fetal diseases or twin pregnancies occurred in 87.9%. Preeclampsia/HELLP syndrome developed in 31.3% but were mostly mild or moderate (65.4%). However, severe adverse outcome was observed in 36.1% with severe preeclampsia in 10.8%. Even if further pregnancy duration and gestational week correlated negatively (r=-0.424; p<0.001), 92% of patients, tested with <340 weeks delivered prematurely. The overall preterm birth rate was 27.7%. Patients with an intermediate sFlt-1/PlGF ratio are at risk for severe adverse outcome. An intermediate sFlt-1/PlGF ratio indicates a risk for preterm birth, independent from the occurrence of preeclampsia.

OP 16 An intermediate sFlt-1/PlGF ratio indicates an increased risk for adverse pregnancy outcome

Current concepts understand preeclampsia as an altered angiogenic state. The sFlt-1/PlGF ratio is a valid marker for the diagnosis of preeclampsia and correlates closely with the severity of the disease. A recent case-control study developed gestational age-dependent cut-offs for the sFlt-1/PlGF ratio. The currently used cut offs frame an intermediate zone of 33–85 (<340 weeks) or 33–110 (⩾340 weeks), respectively. In this study we sought to evaluate the relevance of an intermediate sFlt-1/PlGF ratio for the clinical pregnancy course and outcome. We retrospectively analysed 533 consecutive patients with sFlt-1/PlGF ratio measurements for suspected preeclampsia. In patients with an intermediate sFlt-1/PlGF ratio, fetal and maternal characteristics and also pregnancy outcome were documented. Furthermore, we compared the patient groups with <340/340-366/⩾370 gestational weeks at first visit. 83/533 (15.6%) patients had an intermediate sFlt-1/PlGF ratio. Maternal or fetal diseases or twin pregnancies occurred in 87.9%. Preeclampsia/HELLP syndrome developed in 31.3% but were mostly mild or moderate (65.4%). However, severe adverse outcome was observed in 36.1% with severe preeclampsia in 10.8%. Even if further pregnancy duration and gestational week correlated negatively (r = −0.424; p < 0.001), 92% of patients, tested with <340 weeks delivered prematurely. The overall preterm birth rate was 27.7%. Patients with an intermediate sFlt-1/PlGF ratio are at risk for severe adverse outcome. An intermediate sFlt-1/PlGF ratio indicates a risk for preterm birth, independent from the occurrence of preeclampsia.

Behavioral and neural correlates of emotional development: typically developing infants and infants of depressed and/or anxious mothers

ObjectivesTo describe the main findings of studies of behavioral and neural correlates regarding the development of facial emotion processing during the first year of life in typically developing infants and infants of depressed and/or anxious mothers. SourcesComprehensive, non‐systematic review of the literature on studies about individual differences in facial emotion processing by newborns and infants over the first year of life. Summary of the findingsMaternal stress related to depression and anxiety has been associated to atypical emotional processing and attentional behaviors in the offspring. Recent neurophysiological studies using electroencephalogram and event‐related potentials have begun to shed light on the possible mechanisms underlying such behaviors. ConclusionsInfants of depressed and/or anxious mothers have increased risk for several adverse outcomes across the lifespan. Further neurobehavioral investigations and the promotion of clinical and developmental research integration might eventually contribute to refining screening tools, improving treatment, and enabling primary prevention interventions for children at risk.

Behavioral and neural correlates of emotional development: typically developing infants and infants of depressed and/or anxious mothers

ObjectivesTo describe the main findings of studies of behavioral and neural correlates regarding the development of facial emotion processing during the first year of life in typically developing infants and infants of depressed and/or anxious mothers. SourcesComprehensive, non-systematic review of the literature on studies about individual differences in facial emotion processing by newborns and infants over the first year of life. Summary of the findingsMaternal stress related to depression and anxiety has been associated to atypical emotional processing and attentional behaviors in the offspring. Recent neurophysiological studies using electroencephalogram and event-related potentials have begun to shed light on the possible mechanisms underlying such behaviors. ConclusionsInfants of depressed and/or anxious mothers have increased risk for several adverse outcomes across the lifespan. Further neurobehavioral investigations and the promotion of clinical and developmental research integration might eventually contribute to refining screening tools, improving treatment, and enabling primary prevention interventions for children at risk.

Placental Nutrient Transport and Intrauterine Growth Restriction.

Intrauterine growth restriction refers to the inability of the fetus to reach its genetically determined potential size. Fetal growth restriction affects approximately 5–15% of all pregnancies in the United States and Europe. In developing countries the occurrence varies widely between 10 and 55%, impacting about 30 million newborns per year. Besides having high perinatal mortality rates these infants are at greater risk for severe adverse outcomes, such as hypoxic ischemic encephalopathy and cerebral palsy. Moreover, reduced fetal growth has lifelong health consequences, including higher risks of developing metabolic and cardiovascular diseases in adulthood. Numerous reports indicate placental insufficiency as one of the underlying causes leading to altered fetal growth and impaired placental capacity of delivering nutrients to the fetus has been shown to contribute to the etiology of intrauterine growth restriction. Indeed, reduced expression and/or activity of placental nutrient transporters have been demonstrated in several conditions associated with an increased risk of delivering a small or growth restricted infant. This review focuses on human pregnancies and summarizes the changes in placental amino acid, fatty acid, and glucose transport reported in conditions associated with intrauterine growth restriction, such as maternal undernutrition, pre-eclampsia, young maternal age, high altitude and infection.

Unknown Safety and Efficacy of Smartphone Bolus Calculator Apps Puts Patients at Risk for Severe Adverse Outcomes.

Manual calculation of bolus insulin dosages can be challenging for individuals treated with multiple daily insulin injections (MDI) therapy. Automated bolus calculator capability has recently been made available via enhanced blood glucose meters and smartphone apps. Use of this technology has been shown to improve glycemic control and reduce glycemic variability without changing hypoglycemia; however, the clinical utility of app-based bolus calculators has not been demonstrated. Moreover, recent evidence challenges the safety and efficacy of these smartphone apps. Although the ability to automatically calculate bolus insulin dosages addresses a critical need of MDI-treated individuals, this technology raises concerns about efficacy of treatment and the protection of patient safety. This article discusses key issues and considerations associated with automated bolus calculator use.

Lifestyle Intervention in Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) affects up to 30% of adults in Western populations and is increasing in prevalence. GERD is associated with lifestyle factors, particularly obesity and tobacco smoking, which also threatens the patient's general health. GERD carries the risk of several adverse outcomes and there is widespread use of potent acid-inhibitors, which are associated with long-term adverse effects. The aim of this systematic review was to assess the role of lifestyle intervention in the treatment of GERD. Literature searches were performed in PubMed (from 1946), EMBASE (from 1980), and the Cochrane Library (no start date) to October 1, 2014. Meta-analyses, systematic reviews, randomized clinical trials (RCTs), and prospective observational studies were included. Weight loss was followed by decreased time with esophageal acid exposure in 2 RCTs (from 5.6% to 3.7% and from 8.0% to 5.5%), and reduced reflux symptoms in prospective observational studies. Tobacco smoking cessation reduced reflux symptoms in normal-weight individuals in a large prospective cohort study (odds ratio, 5.67). In RCTs, late evening meals increased time with supine acid exposure compared with early meals (5.2% point change), and head-of-the-bed elevation decreased time with supine acid exposure compared with a flat position (from 21% to 15%). Weight loss and tobacco smoking cessation should be recommended to GERD patients who are obese and smoke, respectively. Avoiding late evening meals and head-of-the-bed elevation is effective in nocturnal GERD.

Modeling risk for severe adverse outcomes using angiogenic factor measurements in women with suspected preterm preeclampsia.

IntroductionPreeclampsia (PE) is a pregnancy-specific syndrome associated with adverse maternal and fetal outcomes. Patient-specific risks based on angiogenic factors might better categorize those who might have a severe adverse outcome.MethodsWomen evaluated for suspected PE at a tertiary hospital (2009–2012) had pregnancy outcomes categorized as ‘referent’ or ‘severe’, based solely on maternal/fetal findings. Outcomes that may have been influenced by a PE diagnosis were considered ‘unclassified’. Soluble fms-like tyrosine kinase (sFlt1) and placental growth factor (PlGF) were subjected to bivariate discriminant modeling, allowing patient-specific risks to be assigned for severe outcomes.ResultsThree hundred twenty-eight singleton pregnancies presented at ≤34.0 weeks' gestation. sFlt1 and PlGF levels were adjusted for gestational age. Risks above 5 : 1 (10-fold over background) occurred in 77% of severe (95% CI 66 to 87%) and 0.7% of referent (95% CI <0.1 to 3.8%) outcomes. Positive likelihood ratios for the modeling and validation datasets were 19 (95% CI 6.2–58) and 15 (95% CI 5.8–40) fold, respectively.ConclusionsThis validated model assigns patient-specific risks of any severe outcome among women attending PE triage. In practice, women with high risks would receive close surveillance with the added potential for reducing unnecessary preterm deliveries among remaining women. © 2015 The Authors. Prenatal Diagnosis published by John Wiley & Sons Ltd.

Violence, suicide, and all-cause mortality

In their article in The Lancet Psychiatry, Seena Fazel and colleagues 1 argue persuasively that although people with schizophrenia and related disorders are known to be at an increased risk of adverse outcomes (especially violent crime, premature mortality, and death by suicide) compared with the general population, whether this association represents secular trends or is specific to mental health problems is generally unknown. The authors succeed in advancing understanding about this issue. The simultaneous analysis of suicide, premature mortality, and violent crime offers hope for the streamlining of risk assessment for people with schizophrenia and other psychiatric disorders and encourages assessing clinicians to explore several behaviours. Fazel and colleagues' finding that at least three prediagnosis risk factors--drug use disorders, history of violent criminality, and self-harm--increased the risk for several adverse outcomes has implications for practical population-based strategies. Several questions still remain. To what extent the findings are generalisable to other countries remains unclear. Although the authors state that many similarities exist between Sweden and other high-income countries, it is important to note that research indicates a lower than 10% level of unmet treatment needs in Nordic countries in people who have schizophrenia2 and that the authors report absence of differences when inpatients and outpatients were compared. People with schizophrenia in other countries have varying access to treatment, as discussed by Mojtabai and colleagues,3 who noted in a review that roughly 40% of patients with schizophrenia reported they had not received any mental health treatment in the preceding 6-12 months..... 1. S Fazel, A Wolf, C Palm, P Lichtenstein. Violent crime, suicide, and premature mortality in patients with schizophrenia and related disorders: a 38-year total population study in Sweden. Lancet Psychiatry, 1 (2014), pp. 44-54 2. L Hansson, HR Vinding, T Mackeprang, et al. Comparison of key worker and patient assessment of needs in schizophrenic patients living in the community: a Nordic multicentre study. Acta Psychiatr Scand, 103 (2001), pp. 45-51 Language: en

In Response

In Response

The frailty syndrome

Frailty is an emerging geriatric syndrome with a high prevalence in the community population. It can be seen as a state of extreme vulnerability and loss of resistance to external stressors resulting in an increased risk of several adverse outcomes. Although linked with ageing, disability and co-morbidity, many consider frailty as a distinct clinical and pathophysiological entity. A problem with this concept is the search for a suitable operational definition that can be used in clinical practice. Although many exist in literature, there is no agreement on the best measure. The more popular of these definitions include Fried's model of frailty and the Frailty Index. In addition, the evidence for treatment of frailty is limited, and this raises the question on the usefulness of identifying frailty without any clear interventions to reverse this state.