Value Of Clinical Risk Factors Research Articles

Predictive value of clinical risk factors for bladder dysfunction in Syrian patients with type 2 diabetes mellitus

Diabetes mellitus (DM) is a prevalent disorder that affects the endocrine and metabolic systems. Among the various complications associated with DM, diabetic bladder dysfunction (DBD) is the most frequently occurring genitourinary complication. The presence of DBD can lead to complications that affect the upper urinary tract, significantly impacting the quality of life for individuals with DM. Therefore, it is crucial to identify early risk factors for DBD and predict its onset. Given the absence of studies involving bladder dysfunction in patients with type 2 diabetes mellitus (T2DM) in Syria, this study aims to examine the risk factors associated with bladder dysfunction in T2DM patients and develop a predictive model to identify DBD early. Patients diagnosed with T2DM were enrolled in six endocrinology centers spread across four Syrian provinces between January 2018 and December 2023. Factors that showed an association with DBD in the bivariate analysis, with a significance level of p < 0.05, were included in a multiple logistic regression analysis. The logistic regression analysis was used to identify independent risk factors and develop a prediction model. The receiver operating characteristic (ROC) curve was used to assess the predictive performance of the identified risk factors and the prediction model for DBD. One hundred and eighty-four patients were included in this study, and they were divided into the DBD group (n = 88) and the non‐DBD group (n = 96). Seven variables showed significance in the bivariate analysis. Furthermore, the multiple logistic regression analysis revealed that age (OR [95% CI]: 0.981 [0.614 − 1.337]), p < 0.007; diabetic peripheral neuropathy (DPN) (OR [95% CI]: 1.421 [1.027 − 3.308]), p = 0.03; glycated hemoglobin (HbA1c) (OR [95% CI]: 0.942 [0.821 − 1.141]), p = 0.042; and percentage of monocyte (Mono%) (OR [95% CI]: 1.109 [0.812 − 1.258]), p = 0.031 were independent risk factors for DBD. Analysis of the ROC curve revealed that the area under the curve (AUC) for age, DPN, HbA1c, and Mono were 0.703, 0.541, 0.613, and 0.836, respectively. Age, DPN, HbA1c, and Mono% were risk factors for DBD. The prediction model constructed based on the four risk factors had a good predictive value for predicting the occurrence of DBD.

Prognosis with non-contrast CT and CT Perfusion imaging in thrombolysis-treated acute ischemic stroke

Background and purposeThe Alberta Stroke Program Early CT Score (ASPECTS) and hyperdense vessel sign (HDVS) on baseline non-contrast CT (NCCT) may benefit prognosis of acute ischemic stroke (AIS). We aimed to investigate the agreement of ASPECTS between automated and manual interpretations, and further understand the roles of NCCT and CT Perfusion (CTP) in prognosis. Materials and MethodsFrom January 2019 to May 2020, thrombolysis-treated AIS patients undergoing NCCT and Perfusion imaging before treatment were retrospectively reviewed. A radiologist, a senior neuroradiologist and a neurologist blindly interpreted ASPECTS from NCCT images and a prototypical software produced automated results. Another independent radiologist determined presence of HDVS and CTP-ASPECTS. Three-month modified Rankin scale (mRS) ≤ 2 indicated good functional outcome. NCCT ASPECTS were compared against CTP-ASPECTS using squared weighted kappa. Univariable, multivariable and receiver operating characteristics (ROC) analysis were conducted to evaluate the prognostic value of clinical risk factors, NCCT and CTP findings. ResultsSeventy-five patients were included in this study, of whom 35 (46.7%) presented favorable outcome. Fair to substantial agreement with CTP-ASPECTS was witnessed for automated and manual interpretations (0.685, automated; 0.778, radiologist; 0.830, neuroradiologist; 0.313, neurologist). ASPECTS, HDVS, infarct core volume and mismatch ratio were univariably related to functional outcome, and infarct core volume remained as an independent prognostic factor in the multivariable analysis. The multivariable model achieved an area under ROC (AUC) of 0.768 (95% CI, 0.666–0.870). ConclusionsAutomated ASPECTS achieves substantial agreement with reference CTP-ASPECTS, and comprehensive CT assessment may benefit AIS prognosis after intravenous thrombolysis.

Clinical risk factors and P wave indices in prediction of atrial fibrillation development during long-term follow-up after acute ST-segment elevation myocardial infarction

Abstract Introduction In patients with high thromboembolic risk detection of atrial fibrillation (AF) is crucial for implementation of proper anticoagulation therapy, which highlights the need for identification of patients at risk for AF. P wave indices reflect atrial structural abnormalities linked to AF development. Purpose We aimed to assess the value of clinical risk factors and P wave indices in prediction of incident AF after acute ST-segment elevation myocardial infarction (STEMI) in patients undergoing primary percutaneous intervention (PCI). Methods Study sample comprised of 2277 consecutive patients with STEMI admitted to a tertiary care hospital for primary PCI from 2007 to 2010. SWEDEHEART registry was used as the source of information regarding clinical characteristics and events during index admission. Patients without known AF at discharge were included in the current study (n=1837, mean age 65±12 years, 30% females). AF in follow-up (median 9, interquartile range 25–75% (IQR) 7–10 years) was documented by linkage with the Swedish National Patient Register and Swedish Cause-of-Death Register. The closest available ECGs prior to STEMI (median 448, interquartile rate 25–75% 112–1390 days before STEMI) were extracted from the regional electronic ECG databases and automatically processed using Glasgow algorithm. P-wave duration, PR interval, P-wave frontal axis and P terminal force in lead V1 (PTF-V1) were assessed. PTF-V1 &amp;gt;40 mm*ms was considered abnormal. Results In follow-up incident AF was documented in 285 patients (15.4%). In univariate Cox regression analysis age, hypertension, history of myocardial infarction, heart failure, history of stroke, smoking status, P wave duration &amp;gt;120 ms, PR interval and abnormal PTF-V1 predicted the AF development during follow-up (Table). In multivariate Cox regression analysis in which significantly associated variables were included only age (hazard ratio (HR) 1.07, 95% CI 1.05–1.08, p&amp;lt;0.001) and abnormal PTF-V1 (HR 1.49, 95% CI 1.08–2.05, p=0.015, Figure) remained independent predictors of incident AF. Conclusion In patients with acute STEMI incident AF developed during long-term follow-up after discharge from hospital was strongly associated with age and atrial structural abnormalities reflected as abnormal PTF-V1 on pre-STEMI ECG which might serve as a tool in risk stratification of STEMI patients in regard to AF development. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Scholarship grant from Swedish Institute. Table 1Figure 1

Malignant ventricular arrhythmias and other complications of untreated accessory pathways: an analysis of prevalence and risk factors in over 600 ablation cases.

The presence of accessory pathways (APs) is a risk factor for sudden cardiac death and other clinical complications. We aimed to characterize all adverse events likely related to the presence of APs in patients referred for AP ablation and to identify risk factors for malignant arrhythmias. We performed a retrospective analysis of consecutive patients referred for AP ablation from 2002 to 2017. Electrocardiograms, electrophysiological system records, and hospital discharge notes were reviewed. We collected data concerning symptoms before ablation, occurrence of ventricular fibrillation or malignant atrial fibrillation (AF), as well as other complications related to APs. We identified 602 patients with APs. Serious AP‑related events were observed in 41 patients, including 14 sudden cardiac arrests (1 death) and 16 pre–cardiac arrest events. Other complications included strokes, pulmonary edema, heart failure, and unnecessary device implantation. The risk of malignant arrhythmias decreased with a longer shortest preexcited RR interval (per 10 ms: odds ratio [OR], 1.3; 95% CI, 1.16–1.47) and increased with age (per 10 years: OR, 1.29; 95% CI, 1.06–1.57). The presence of inducible AF, but not sole atrioventricular reentrant tachycardia, increased the risk for malignant arrhythmias when compared with patients without any inducible arrhythmias. Patients with APs referred for ablation commonly present with various adverse events. The predictive value of clinical risk factors for malignant arrhythmias is too low to prevent devastating consequences. When high safety and efficacy of AP ablation are ensured, even a low risk of sudden death is unacceptable and a lower threshold for prophylactic ablation should be used to prevent AP‑related adverse events.

Clinical risk factors for new-onset atrial fibrillation in acute myocardial infarction: A systematic review and meta-analysis.

New-onset atrial fibrillation (NOAF) remains common arrhythmia in acute myocardial infarction (AMI), and is closely associated with increased subsequent cardiovascular mortality. Our meta-analysis aims to summarize more clinical risk factors for NOAF.Comprehensive systematic search of MEDLINE, EMBASE, and the Cochrane Library were carried out to find relevant studies inception to December 2017. Pooled mean difference (MD) and 95% confidence interval (CI) were calculated to evaluate the value of clinical risk factors in the prediction of NOAF after AMI.Eleven studies containing 9570 patients were included in the meta-analysis. Overall, older age and increased heart rate (HR) levels had a significant positive association with NOAF in patients with AMI. The MD in age between the patients with, and those without NOAF, was 8.22 units (95% confidence interval [CI]: 7.44-9.01), test for overall effect z score = 20.51 (P < .00001, I = 0%). Moreover, the MD in a subgroup analysis for HR levels between the patients with, and those without NOAF was 4.34 units (95% Cl: 2.56-6.11), test for overall effect z score = 4.78 (P < .00001, I = 31%).In patient with AMI, our meta-analysis demonstrated that older age and increased HR levels on admission are related to greater risk of NOAF.

An Optimised Fracture Liaison Service Model: Maintained Diagnostic Sensitivity Despite Reduced Number of Diagnostic Tests Performed.

Patients suffering a low-energy fracture are at high risk of subsequent fractures. Investigation of all fragility fracture patients above the age of 50years is recommended in order to prevent further fractures. The aim of this study was to investigate alternative strategies including known risk factors (age, sex, and body weight) for selecting fracture patients for osteoporosis assessment and investigate how these strategies would affect the proportion of patients with osteoporosis identified and the number of patients referred for Dual X-ray Absorptiometry (DXA) compared with the original FLS strategy. From OFELIA; a cohort study comprising 794 fragility fracture patients we included 622 patients aged 18 + years (mean age 56 ± 17) with fragility fractures. We investigated the predictive value of clinical risk factors using ROC curves and AUC analyses. The revised strategies were compared by analyzing sensitivity and specificity of different strategies based on sex, age, BMI, and bodyweight. For patients 50 + years, a strategy investigating men and women with body weight ≤ 85kg resulted in sensitivity and specificity of 94% and 25%, respectively, reducing the number of DXAs by 21%. For patients < 50 years, the prevalence of osteoporosis was low and it was, therefore, difficult to develop an acceptable strategy. We found that the original FLS strategy can be modified to include substantially fewer patients and still only miss the osteoporosis diagnosis in a very few patients. A modified strategy would potentially save costs and concerns in many patients.

Alternative Response Criteria and Clinical Risk Factors for Assessing Tumor Response in Patients With Metastatic Renal Cell Carcinoma Who Are Receiving Salvage Therapy.

The purpose of this study is to compare the prognostic value of various solid tumor response criteria as well as the additive value of clinical risk factors in patients with advanced renal cell carcinoma (RCC). Two sets of CT scans (pretreatment scans and scans obtained 1-3.5 months after treatment) were reviewed for 57 patients with metastatic RCC treated with pazopanib in the salvage setting. Tumor response on the posttherapy scan was evaluated using Response Evaluation Criteria in Solid Tumors (RECIST) and Choi, modified Choi (mChoi), MASS (Morphology, Attenuation, Size, and Structure), and 10% threshold criteria. In addition, combined Memorial Sloan-Kettering Cancer Center (MSKCC) risk factors plus imaging criteria were used to define response groups. Response evaluations using these criteria were correlated with overall survival (OS) and progression-free survival (PFS), with use of the log-rank test. Patients classified as having progressive disease (PD) on the basis of RECIST, mChoi, and MASS criteria had a significantly worse OS than patients with stable disease (SD) and partial response (PR). With the addition of MSKCC risk factors, all groups with PD defined by combined criteria had significantly worse OS. For 37 patients with no or one MSKCC risk factor, response groups defined by Choi, mChoi, MASS, and 10% threshold criteria did not differ in PFS or OS. However, among 20 patients with two to three MSKCC risk factors, those classified as having PR had longer PFS than did those with SD and had longer OS than did those with PD. For patients with advanced RCC for which prior therapies have failed, the prognostic value of various imaging-based tumor response criteria differs on the basis of the MSKCC clinical risk status.

Prognostic Value of Risk Factors, Calcium Score, Coronary CTA, Myocardial Perfusion Imaging, and Invasive Coronary Angiography in Kidney Transplantation Candidates

ObjectivesThis study sought to perform a prospective head-to-head comparison of the predictive value of clinical risk factors and a variety of cardiac imaging modalities including coronary artery calcium score (CACS), coronary computed tomography angiography (CTA), single-photon emission computed tomography (SPECT), and invasive coronary angiography (ICA) on major adverse cardiac events (MACE) and all-cause mortality in kidney transplantation candidates. BackgroundCurrent guidelines recommend screening for coronary artery disease in kidney transplantation candidates. Furthermore, noninvasive stress imaging is recommended in current guidelines, despite its low diagnostic accuracy and uncertain prognostic value. MethodsThe study prospectively evaluated 154 patients referred for kidney transplantation. All patients underwent CACS, coronary CTA, SPECT, and ICA testing. The clinical endpoints were extracted from patients’ interviews, patients’ records, and registries. ResultsThe mean follow-up time was 3.7 years. In total, 27 (17.5%) patients experienced MACE, and 31 (20.1%) patients died during follow-up. In a time-to-event analysis, both risk factors and CACS significantly predicted death, but only CACS predicted MACE. Combining risk factors with CACS identified a very-low-risk cohort with a MACE event rate of 2.1%, and a 1.0% mortality rate per year. Of the diagnostic modalities, coronary CTA and ICA significantly predicted MACE, but only coronary CTA predicted death. In contrast, SPECT predicted neither MACE nor death. ConclusionsCompared with traditional risk factors and other cardiac imaging modalities, CACS and coronary CTA seem superior for risk stratification in kidney transplant candidates. Applying a combination of risk factors and CACS and subsequently coronary CTA seems to be the most appropriate strategy. (Angiographic CT of Renal Transplantation Candidate Study [ACToR]; NCT01344434)

Distribution of clinical risk factors for fracture in a Brussels cohort of postmenopausal women: The FRISBEE study and comparison with other major cohort studies

ObjectivesThe estimation of fracture risk using clinical risk factors (CRFs) is of primary concern in osteoporosis management, but only some risk factors have been thoroughly evaluated and incorporated in predictive models. We have launched a large prospective study, the ‘Fracture Risk Brussels Epidemiological Enquiry’ (FRISBEE), to develop a new predictive model for osteoporotic fractures. The aims of this report are to describe the methodology of the FRISBEE study and to compare the distribution of CRFs in our cohort with those reported in other large studies. Study designFRISBEE is a new study that prospectively evaluates a cohort of 3560 post-menopausal women (aged 60–85 years) followed yearly for the occurrence of fragility fractures. Multiple validated CRFs, densitometry (DXA) values and intake of medication were systematically registered at baseline. The distribution of the FRISBEE CRFs has been compared with the distributions of CRFs in the cohorts used to develop the FRAX® model as well as in more recent cohorts. For these recent cohorts, we focused on CRFs not included in FRAX®. ResultsThe most frequently encountered CRFs used in FRAX® were a prior fragility fracture (27.1%) and a parental history of hip fracture (13.4%). The prevalence of some CRFs not integrated in FRAX® was relatively high, such as the use of proton pump inhibitors (20.8%) and a history of fall(s) (19.7%). The prevalence of many CRFs was quite variable between cohorts; for example, the prevalence of ‘personal prior fragility fracture’ ranged from 9% to 51%. ConclusionWe found considerable heterogeneity in the prevalence of CRFs between cohort studies. The impact of these differences on the predictive value of a particular CRF is unknown. We will construct a predictive model calibrated to the Belgian population. More importantly, the FRISBEE study should allow us to determine the predictive value of newly recognized CRFs in addition to the FRAX® algorithm to reliably estimate fracture risk.

The contribution of hip geometry to the prediction of hip osteoarthritis

To determine how well measures of hip geometry can predict radiological incident hip osteoarthritis (HOA) compared to well known clinical risk factors. The study population is part of the Rotterdam Study, a prospective population-based cohort. Baseline pelvic radiographs were used to measure hip geometry by two methods: Statistical Shape Models (SSM) and predefined geometry parameters (PGPs). Incident HOA (Kellgren and Lawrence (KL)≥2) was assessed in 688 participants after 6.5 years without radiographic HOA at baseline. The ability to predict HOA was quantified using the area under the Receiver Operating Characteristics (ROC) curve (AUC). Comparison of the two methods showed that both contain information that is not captured by the other method. At 6.5 years follow-up 132 hips had incident HOA. Five PGPs (Wiberg angle, Neck Width (NW), Pelvic Width (PW), Hip Axis Length (HAL) and Triangular Index (TI)) and two SSM (modes 5 and 9) were significant predictors of HOA (P=0.007). Hip geometry added 7% to the prediction obtained by clinical risk factors (AUC=0.67 (geometry), 0.66 (gender, age, Body Mass Index (BMI)) and combining both: AUC=0.73, respectively). Mode 12 (associated with position of the femoral head in acetabulum) and Wiberg angle were predictors of HOA in participants without radiological signs at baseline (KL=0). Although the strength of the prediction decreased for all variables at a longer follow-up, the contribution of hip geometry was still significant (P = 0.01). Hip geometry has a moderate ability to predict HOA in participants with and without initial signs of osteoarthritis (OA), similar to and largely independent of the predictive value of clinical risk factors.

The risk of foot ulceration in people with diabetes screened in community settings: findings from a cohort study

Annual foot checks are recommended in patients with diabetes mellitus (DM) to identify those at risk of foot ulceration. Systematic reviews have found few studies evaluating the predictive value of tests in community-based diabetic populations. To quantify the predictive value of clinical risk factors in relation to foot ulceration in a community population. A cohort of 1192 people with diabetes receiving care in community settings was recruited and a screening procedure, covering symptoms, signs and diagnostic tests was conducted at baseline. At an average 1-year follow-up patients who developed a foot ulcer were identified by an independent blind assessor. Multivariable analysis was performed to identify clinical predictors of foot ulceration. The incidence of foot ulceration was 1.93% [95% confidence interval (CI) 1.27-2.89). Three time-independent clinical predictors with five factors were selected: previous amputation [odds ratio (OR) 14.7, 95% CI 3.1-69.5), use of insulin before 3 months with inability to distinguish between cool and cold temperatures (OR 2.97, 95% CI 1.9-4.5) and failure to obtain at least one blood pressure reading for the calculation of ankle-brachial index with the failure to feel touch with a 10-g monofilament (OR 1.7, 95% CI 1.3-2.2). Recommendations for annual diabetic foot check in low-risk, community-based patients should be reviewed as absolute events of ulceration are low. The accuracy of foot risk assessment tools to predict ulceration requires evaluation in randomized controlled trials with concurrent economic evaluations.

Dobutamine stress echocardiography predicts cardiac events or death in asymptomatic patients long-term after heart transplantation: 4-Year prospective evaluation

Background Cardiac allograft vasculopathy (CAV) remains the major cause of death after cardiac transplantation during long-term follow-up. Nevertheless, annual angiographic evaluation is difficult to perform routinely. We evaluated the value of clinical risk factors and non-invasive testing for cardiac allograft vasculopathy in predicting cardiac events or death in asymptomatic patients with normal ventricular function during long-term follow-up after heart transplantation. Methods We studied 39 patients, mean aged 48 ± 13 years, at 86 ± 31 months after heart transplantation. Patients underwent thallium scintigraphy, treadmill stress testing, dobutamine stress echocardiography, and angiography to detect CAV. We prospectively observed all patients an additional 4 years for acute myocardial infarction, congestive heart failure, or death. Results Angiography detected CAV in 15 patients (38%). Three patients had acute myocardial infarction and another 7 had congestive heart failure, representing 25% of cardiac events during the study period. Nine deaths (23%) occurred during the same observation time. Univariate analysis showed that increased body mass index, positive dobutamine stress echocardiography results, and positive angiography results were associated significantly with cardiac events or death during follow-up. In the absence of coronary angiography, stepwise logistic regression identified positive dobutamine echocardiography results as the unique independent predictor of cardiac events ( p = 0.001) or death ( p = 0.002). Conclusion Cardiac events and death after heart transplantation increased during long-term follow-up of this population. However, dobutamine stress echocardiography is well tolerated and, in the absence of routine angiographic evaluation, may be a strong predictor of these events.

INTRAPARTUM FETAL SURVEILLANCE: Is It Worthwhile?

Potentially significant intrapartum fetal asphyxia occurs in approximately 20 per 1000 births. Moderate and severe fetal asphyxia exposure with newborn morbidity occurs in 3 to 4 1000 births, with brain damage and subsequent disability in at least 1 per 1000 births. Although the prevalence of moderate and severe asphyxia is modest, prevention is important because of the serious implications of this complication to the child, family, and society. Because of the limited predictive value of clinical risk factors, the interpretation of patterns in a fetal heart rate record has become the primary screening test for intrapartum fetal asphyxia. Despite extensive clinic experience and numerous clinical trials, the benefits of EFM as a screening test have not been established, and harm may occur owing to unnecessary intervention. This observation raises serious ethical issues. When an intervention is initiated by the clinician rather than the patient, the clinician under greater obligation to ensure that the benefits outweigh the harm. Several factors complicate the demonstration of benefits of EFM as a screening test. There is no consensus regarding a protocol of fetal surveillance for low-risk patient who account for approximately 25% of intrapartum fetal asphyxia. Moderate and severe asphyxia cannot be prevented when asphyxial exposure has occurred before labor or before the onset of fetal surveillance. Prediction of intrapartum fetal asphyxia cannot occur when the quality of the record does not permit interpretation. Interpretation of predictive fetal heart rate patterns cannot occur unless the record is consistently and carefully scored. Prediction of most cases of intrapartum fetal asphyxia on the basis of fetal heart rate patterns is possible but difficult. Because the goal of intrapartum fetal surveillance is the prevention of moderate and severe fetal asphyxia, prediction must be achieved before fetal decompensation. Prediction must occur before absent baseline fetal heart rate variability evident in the record, which is uniformly associated with cerebral dysfunction and, in some cases, brain damage. The possibility of fetal asphyxia must be considered when, within a 1-hour window of recording, there are two or more cycles of minimal baseline fetal heart rate variability and two or more cycles of late or prolonged decelerations or both. Because approximately 9 of 10 predictive fetal heart rate patterns are false-positive, supplementary tests to confirm the diagnosis and to identify false-positives to prevent unnecessary intervention are essential. Until such time as additional fetal assessment tests are validated, blood gas and acid-base assessment of fetal blood can provide a definitive diagnosis and identify false-positive predictions.

How should the risk of fracture in postmenopausal women be assessed?

Osteoporosis is a ‘progressive systemic skeletal disease characterized by a low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in skeletal fragility and susceptibility to fractures’ [1]. This new definition implies that the diagnosis can (and probably should) be performed before any fragility fracture has occurred, which is a challenge for the clinician. The level of bone mass can be assessed with reasonable accuracy by measuring the bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA), but that measurement does not capture all risk factors for fracture. Bone fragility also depends on the microstructural architecture of bone (i.e. the ‘quality’ of bone), which cannot readily be assessed but which may be partly approached by ultrasonic measurements of bone and indirectly by measuring bone turnover with specific serum and urinary markers of bone formation and resorption rates. In addition, the risk of fracture is influenced by the propensity to fall, and the ability to adapt to such falls, and these extraskeletal risk factors for fracture can be evaluated with simple questionnaire and clinical tests. This paper will briefly review the diagnostic value of clinical risk factors, bone assessment by DXA and ultrasound, and biochemical indices, and will discuss the potential utility of combining these various tests of fracture risk.

Limitations in the clinical prediction of intrapartum fetal asphyxia

OBJECTIVE: Our purpose was to demonstrate the predictive value of clinical risk scoring and fetal assessment for intrapartum fetal asphyxia. STUDY DESIGN: Intrapartum fetal asphyxia was defined by an umbilical artery buffer base <34 mmol/L. The predictive value of 20 antepartum and intrapartum risk factors was examined in 1909 consecutive pregnancies. The predictive value of clinical risk factors with periodic fetal assessment was examined in a second population of 100 consecutive pregnancies with biochemically determined intrapartum fetal asphyxia. RESULTS: The incidence of intrapartum was 2.3%. Two problems were apparent in these studies. A significant proportion of intrapartum fetal asphyxia occurred in pregnancies with no risk factors. The positive predictive value of clinical risk factors was low, 3%, resulting in a large number of false positives requiring clarification. CONCLUSION: Screening and fetal assessment methods must be improved to ensure the early recognition of intrapartum fetal asphyxia that may require intervention during labor to avoid morbidity and mortality.