Cost-effectiveness of first-trimester screening with early preventative use of aspirin in women at high risk of early-onset pre-eclampsia.

OBJECTIVE: Pre-eclampsia (PE) remains a leading cause of maternal and fetal morbidity and mortality. A first-trimester screening algorithm predicting the risk of early-onset PE has been developed and validated. Early prediction coupled with initiation of aspirin at 11-13 weeks in women identified as high risk is effective at reducing the prevalence of early-onset PE. The aim of this study was to evaluate the cost-effectiveness of this first-trimester screening program coupled with early use of low-dose aspirin in women at high risk of developing early-onset PE, in comparison to current practice in Canada. METHODS: A decision analysis was performed based on a theoretical population of 387 516 live births in Canada in 1 year. The clinical and financial impact of early preventative screening using the Fetal Medicine Foundation algorithm for prediction of early-onset PE coupled with early (< 16 weeks) use of low-dose aspirin in those at high risk was simulated and compared with current practice using decision-tree analysis. The probabilities at each decision point and associated costs of utilized resources were calculated based on published literature and public databases. RESULTS: Of the theoretical 387 516 births per year, the estimated prevalence of early PE based on first-trimester screening and aspirin use was 705 vs 1801 cases based on the current practice. This was associated with an estimated total cost of C$9.52 million with the first-trimester screening program compared with C$23.91 million with current practice for the diagnosis and management of women with early-onset PE. This equals an annual cost saving to the Canadian healthcare system of approximately C$14.39 million. CONCLUSIONS: The implementation of a first-trimester screening program for PE and early intervention with aspirin in women identified as high risk for early PE has the potential to prevent a significant number of early-onset PE cases with a substantial associated cost saving to the healthcare system in Canada. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Transverse technique: complementary approach to measurement of first-trimester uterine artery Doppler.

OBJECTIVES: To define a protocol for the first-trimester assessment of uterine artery pulsatility index (UtA-PI) using the new transverse technique, to evaluate UtA-PI measured using the transverse approach vs that obtained using the conventional sagittal approach and to determine if accelerated onsite training (in both methods) of inexperienced sonographers can achieve reproducible UtA-PI measurements comparable with those obtained by an experienced sonographer. METHODS: This was a prospective observational study of women with a singleton pregnancy attending for routine combined first-trimester screening at 11 to 13 + 6 weeks' gestation. The study consisted of two parts, each conducted at a different center (Part 1 in Calgary, Canada and Part 2 in Hong Kong). In Part 1, UtA-PI measurements were performed using the transverse and sagittal techniques by four sonographers trained in both methods, in 10 cases each, and measurement indices (PI), time required and subjective difficulty in obtaining satisfactory measurements were compared. The one sample t-test and Wilcoxon signed rank test were used when appropriate. Bland-Altman plots were used to assess measurement agreement, and intraclass correlation coefficient (ICC) was used to evaluate measurement reliability. A target plot was used to assess measures of central tendency and dispersion. In Part 2, one experienced and three inexperienced sonographers prospectively measured UtA-PI using both approaches in 42 and 35 women, respectively. Inexperienced sonographers underwent accelerated onsite training by the experienced sonographer. Measurement approach and sonographer order were on a random basis. ICC, Bland-Altman and Passing-Bablok analyses were performed to assess measurement agreement and reliability and effect of accelerated training. RESULTS: In Part 1, no difference was observed between the two techniques in mean time to acquire the measurements (118 s for sagittal vs 106 s for transverse; P = 0.38). The four sonographers reported that the transverse technique was subjectively easier to perform (P = 0.04). Bias and ICC for mean UtA-PI between sagittal and transverse measurements were -0.05 (95% limits of agreement, -0.48 to 0.37) and 0.94, respectively. Measurements obtained using the transverse technique after correcting for gestational age were significantly closer to the expected distribution than those obtained using the sagittal technique. In Part 2, there were no significant differences in median UtA-PI measured using the different approaches for both experienced and inexperienced sonographers (P > 0.05 for all sonographers). Mean UtA-PI measurement reliability between approaches was high for the experienced (ICC = 0.92) and inexperienced (ICC > 0.80) sonographers. UtA-PI measurement approaches did not deviate from linearity, while bias ranged from -0.10 to 0.07. The median time required was similar between the techniques (56.1 s for sagittal vs 49.3 s for transverse; P = 0.054). CONCLUSIONS: This novel transverse approach for the measurement of UtA-PI in the first trimester appears to be comparable with the sagittal approach in terms of reliability, reproducibility and time required, and may be easier to perform. Providing accelerated onsite training can be helpful for improving the reliability of UtA-PI measurements and could potentially facilitate the broad implementation of first-trimester pre-eclampsia screening. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Validation of an obstetric comorbidity index in an external population.

OBJECTIVES: An obstetric comorbidity index has been developed recently with superior performance characteristics relative to general comorbidity measures in an obstetric population. This study aimed to externally validate this index and to examine the impact of including hospitalisation/delivery records only when estimating comorbidity prevalence and discriminative performance of the obstetric comorbidity index. DESIGN: Validation study. SETTING: Alberta, Canada. POPULATION: Pregnant women who delivered a live or stillborn infant in hospital (n = 5995). METHODS: Administrative databases were linked to create a population-based cohort. Comorbid conditions were identified from diagnoses for the delivery hospitalisation, all hospitalisations and all healthcare contacts (i.e. hospitalisations, emergency room visits and physician visits) that occurred during pregnancy and 3 months pre-conception. Logistic regression was used to test the discriminative performance of the comorbidity index. MAIN OUTCOME MEASURES: Maternal end-organ damage and extended length of stay for delivery. RESULTS: Although prevalence estimates for comorbid conditions were consistently lower in delivery records and hospitalisation data than in data for all healthcare contacts, the discriminative performance of the comorbidity index was constant for maternal end-organ damage [all healthcare contacts area under the receiver operating characteristic curve (AUC) = 0.70; hospitalisation data AUC = 0.67; delivery data AUC = 0.65] and extended length of stay for delivery (all healthcare contacts AUC = 0.60; hospitalisation data AUC = 0.58; delivery data AUC = 0.58). CONCLUSIONS: The obstetric comorbidity index shows similar performance characteristics in an external population and is a valid measure of comorbidity in an obstetric population. Furthermore, the discriminative performance of the comorbidity index was similar for comorbidities ascertained at the time of delivery, in hospitalisation data or through all healthcare contacts.

An assessment of the risk factors for Type 2 diabetes among women in rural Jamaica / Valoración de los factores de riesgo en la diabetes tipo 2 entre las mujeres en Jamaica rural

This project examined risk factors (lifestyle, socio-economic and cultural) for Type 2 diabetes among 890 women in rural Jamaica in comparison to national and international trends via the Behavioural Risk Factor Surveillance System (BRFSS) and further analysis via the Kruskal Wallis and Mann-Whitney U tests. Nonparametric tests explored the relationship of body mass index (BMI) and risk factors. Women above age 36 years, sedentary women and women with health insurance showed a significant increase in BMI. Seventh Day Adventists had significantly lower BMIs compared to Protestants. Prevalence of Type 2 diabetes in rural Jamaica is complicated by the lack of adequate health insurance, health practitioners (including dieticians and social workers), and vigorous public awareness campaigns, as well as high healthcare costs. Recommendations include the establishment of a comprehensive plan targeting women to reduce their risk factors for Type 2 diabetes, including early diagnoses, continuing education for healthcare providers and community mobilization among churches, schools, banks, pharmacies and other entities.

Este trabajo examina los factores de riesgo de la diabetes tipo 2 (estilo de vida, condiciones socio-económicas y culturales) entre 890 mujeres de la zona rural de Jamaica, comparados con las tendencias nacionales e internacionales. Para ello se recurrió al Sistema de vigilancia de factores de riesgo conductuales (BRFSS), y un análisis posterior mediante la prueba de Kruskal-Wallis y la prueba U de Mann-Whitney. Se usaron pruebas no paramétricas para explorar la relación del IMC y los factores de riesgo de la diabetes. Las mujeres mayores de 36 años, las mujeres sedentarias, y las mujeres con seguro de salud, mostraron un aumento significativo del índice masa corporal (IMC). Las mujeres Adventistas de Séptimo Día, tenían índices IMC más bajos con relación a las protestantes. La prevalencia de la diabetes de tipo 2 en Jamaica rural, se complica por la falta de seguros de salud adecuados, insuficiente número de profesionales de la salud (incluyendo diteístas y trabajadores sociales), la escasa promoción de campañas vigorosas de concientización pública, y finalmente los altos costos de la atención a la salud. Las recomendaciones incluyen la implementación de un plan integral dirigido a las mujeres y encaminado a reducir los factores de riesgo de la diabetes de tipo 2. Dicho plan incluiría diagnósticos tempranos, educación continuada para los profesionales de la salud, y movilización de la comunidad en asociación con iglesias, escuelas, bancos, farmacias y otras entidades.

Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial / Efectos del ácido tranexámico sobre la mortalidad, eventos oclusivos vasculares y transfusiones de sangre en pacientes con traumatismos con hemorragias significativas (CRASH-2): estudio aleatorio, controlado con placebo

BACKGROUND: Tranexamic acid can reduce bleeding in patients undergoing elective surgery. We assessed the effects of early administration of a short course of tranexamic acid on death, vascular occlusive events, and the receipt of blood transfusion in trauma patients. METHODS: This randomised controlled trial was undertaken in 274 hospitals in 40 countries. 20 211 adult trauma patients with, or at risk of, significant bleeding were randomly assigned within 8 h of injury to either tranexamic acid (loading dose 1 g over 10 min then infusion of 1 g over 8 h) or matching placebo. Randomisation was balanced by centre, with an allocation sequence based on a block size of eight, generated with a computer random number generator. Both participants and study staff (site investigators and trial coordinating centre staff) were masked to treatment allocation. The primary outcome was death in hospital within 4 weeks of injury, and was described with the following categories: bleeding, vascular occlusion (myocardial infarction, stroke and pulmonary embolism), multiorgan failure, head injury, and other. All analyses were by intention to treat. This study is registered as ISRCTN86750102, Clinicaltrials.gov NCT00375258, and South African Clinical Trial Register DOH-27-0607-1919. RESULTS: 10 096patients were allocated to tranexamic acid and 10 115 to placebo, of whom 10 060 and 10 067, respectively, were analysed. All-cause mortality was significantly reduced with tranexamic acid (1463 [14-5%] tranexamic acid group vs 1613 [16-0%] placebo group; relative risk 0-91, 95% CI 0-85-0-97; p = 0-0035). The risk of death due to bleeding was significantly reduced (489 [4-9%] vs 574 [5-7%]; relative risk 0-85, 95% CI 0-76-0-96; p = 0-0077). CONCLUSION: Tranexamic acid safely reduced the risk of death in bleeding trauma patients in this study. On the basis ofthese results, tranexamic acid should be considered for use in bleeding trauma patients.

ANTECEDENTES: El ácido tranexámico puede reducir las hemorragias en pacientes que serán sometidos a cirugía electiva. Evaluamos los efectos de la administración anticipada de un tratamiento de corta duración con ácido tranexámico sobre la mortalidad, los eventos oclusivos vasculares y la administración de transfusiones de sangre en pacientes con traumatismos. MÉTODOS: Este estudio controlado aleatorio se realizó en 274 hospitales distribuidos en 40países. Se asignó en forma aleatoria un total de 20.211 pacientes adultos con traumatismos, con riesgos o no de tener una hemorragia significativa dentro de las 8 horas de la lesión al tratamiento con ácido tranexámico (dosis de carga 1 g durante 10 min. y luego infusión de 1 gen 8 horas) o placebo en forma similar. La distribución aleatoria se equilibró en cada centro, con una secuencia de asignaciones basada en un tamaño de bloque de ocho, generado por un generador de números aleatorios por computadora. Tanto los participantes como el personal del estudio (investigadores del centro y personal del centro que coordinaba el estudio) desconocían la asignación de los tratamientos. El principal resultado fue la mortalidad en el hospital dentro de las 4 semanas de ocurrida la lesión, que se describió con las siguientes categorías: hemorragia, oclusión vascular (infarto de miocardio, accidente cerebrovascular y embolia pulmonar), falla multiorgánica, lesión en la cabeza y otros. Todos los análisis se realizaron con intención de tratar. Este estudio está registrado como ISRCTN86750102, Clinicaltrials.gov NCT00375258, y Registro de Estudios Clínicos Sudafricano DOH-27-0607-1919. RESULTADOS: Se asignaron 10 096 pacientes al tratamiento con ácido tranexámico y 10 115 al tratamiento con placebo, de los cuales se analizaron 10 060 y 10 067, respectivamente. La mortalidad por cualquier causa se redujo significativamente con el tratamiento con ácido tranexámico (1463 [14.5%] del grupo que recibió ácido tranexámico comparados con 1613 [16.0%] del grupo que recibió placebo; riesgo relativo 0.91, 95% CI 0.85-0.97; p = 0.0035). El riesgo de muerte debido a hemorragias se redujo significativamente (489 comparado con 574; riesgo relativo 0.85, 95% CI 0.76-0.96; p = 0.0077). CONCLUSIÓN: En este estudio el ácido tranexámico redujo con seguridad el riesgo de muerte en pacientes con traumatismos hemorrágicos. En base a estos resultados, debe considerarse la utilidad del ácido tranexámico en pacientes con traumatismos hemorrágicos.

Crystallization in heat-treated fluorochlorozirconate glasses.

Crystallization phenomena of fluorochlorozirconate glasses were investigated by means of differential scanning calorimetry and inelastic neutron scattering. The precipitation of barium chloride nanoparticles from the glass matrix upon heat treatment was found to be suppressed when re-melting the glass with a reducing agent but not if the agent was present in the initial synthesis. Addition of small amounts of oxide to the predominantly fluoride melt was found to maintain the presence of nanoparticles but not to induce the predicted phase transition of the barium chloride nanoparticles from hexagonal to orthorhombic structure. Inelastic neutron scattering performed on an 'as-made' glass and a heat-treated glass showed an increase in 'hardness', consistent with a more ordered structure.

Screening for placental insufficiency in high-risk pregnancies: is earlier better?

OBJECTIVE: To compare a profile of placental function between the first and second trimesters in pregnancies at high risk of adverse perinatal outcomes attributable to placental insufficiency. STUDY DESIGN: Prospective cohort study in 61 singleton pregnancies. Uterine artery Doppler and placental morphology (shape and texture) were determined at 11-13(+6) weeks and at 18-23(+6) weeks. First trimester (pregnancy-associated placental protein-A [PAPP-A]) and second trimester (total hCG and alpha fetoprotein [AFP]) serum biochemistry were determined. The two screening periods were compared for the prediction of a range of severe adverse perinatal outcomes (intrauterine growth restriction [IUGR], abruption, severe pre-eclampsia/HELLP syndrome, delivery<32 weeks, or stillbirth). RESULTS: Adverse perinatal outcomes occurred in 14 (23%) women; 3 (4.9%) losses<20 weeks, 2 (3.3%) stillbirths>20 weeks, 4 (6.6%) IUGR, 7 (11.5%) severe pre-eclampsia/HELLP syndrome, and 10 (16.4%) deliveries<32 weeks. Abnormal second trimester placental morphology was significantly associated with adverse outcome [+LR: 3.6, 95% CI: 1.3-8.5; -LR: 0.63, 95% CI: 0.36-0.93; p=0.025], as was > or = 1 abnormal second trimester tests [+LR: 5.9, 95% CI: 1.6-24; -LR: 0.68, 95% CI: 0.59-0.89; p=0.005] or > or = 2 abnormal second trimester tests [+LR: 3.6, 95% CI: 1.3-7.7; -LR: 0.58, 95% CI: 0.27-0.94; p=0.035]. No combination of first trimester tests significantly predicted severe adverse perinatal outcomes. A study sample size of 822 women with similar high-risk characteristics would be needed in order to refute the conclusion that present methods of first trimester screening are not inferior to second trimester screening for severe placental insufficiency (p=0.05, power 80%, z-test). CONCLUSIONS: In clinically high-risk pregnancies, prediction of adverse perinatal outcomes using placental function testing is more effective in the second compared with the first trimester.

Use of an intelligent control system To evaluate multiparametric effects on iron oxidation by thermophilic bacteria

A learning-based intelligent control system, the BioExpert, was developed and applied to the evaluation of multiparametric effects on iron oxidation by enrichment cultures of moderately thermophilic, acidophilic mining bacteria. The control system acquired and analyzed the data and then selected and maintained the sets of conditions that were evaluated. Through multiple iterations, the BioExpert selected sets of conditions that resulted in improved iron oxidation rates. The results obtained with the BioExpert suggested that temperature and pH were coupled, or interactive, parameters. Elevated temperatures (51.5 degreesC) in combination with a moderately high pH (pH 1.84) impaired the growth of and iron oxidation by the enrichment culture. Moderate-to-high oxidation rates were achieved with a relatively high pH in combination with a relatively low temperature or, conversely, with a relatively low pH in combination with a relatively high temperature. The interactive effect of pH and temperature was not apparent from the results obtained in an experiment in which temperature was the only parameter that was varied. When the BioExpert was applied to a mixed culture containing mesophilic and thermophilic bacteria, the computer "learned" that pH 1.8, 45 degreesC, and an inlet iron concentration from 30 to 35 mM were most favorable for iron oxidation. In conclusion, this study demonstrated that the learning-based intelligent control system BioExpert was an effective experimental tool that can be used to examine multiparametric effects on the growth and metabolic activity of mining bacteria.