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1.
Artigo em Inglês | MEDLINE | ID: mdl-33277691

RESUMO

OBJECTIVE: The best screening strategy for gestational diabetes mellitus (GDM) remains a topic of debate. Several organizations made a statement in favor of universal screening, but the involved amount of oral glucose tolerance tests (OGTT) may burden healthcare systems. As a result many countries still rely on selective screening using a checklist of risk factors, but reported diagnostic characteristics vary. Moreover, women's discomfort due to an OGTT is often neglected. Since 2017, obstetric healthcare professionals in a Dutch region assess women's GDM risk with a prediction model and counsel those with an increased risk regarding an OGTT. METHODS: From 2017 to 2018, 865 women were recruited in a multicentre prospective cohort. RESULTS: In total, 385 women (48%) had an increased predicted GDM risk. Of all women, 78% reported their healthcare professional discussed their GDM-risk. Predicted GDM risks were positively correlated with condunting an OGTT. CONCLUSION: Implementation of a GDM prediction model resulted in moderate rates of OGTT's performed in general, but high rates in high-risk women. Since 25% of women experienced discomfort from the OGTT, a selective screening strategy based on a prediction model with a high detection rate may be an interesting alternative to universal screening.

2.
BMC Med ; 18(1): 302, 2020 Nov 02.
Artigo em Inglês | MEDLINE | ID: mdl-33131506

RESUMO

BACKGROUND: Pre-eclampsia is a leading cause of maternal and perinatal mortality and morbidity. Early identification of women at risk during pregnancy is required to plan management. Although there are many published prediction models for pre-eclampsia, few have been validated in external data. Our objective was to externally validate published prediction models for pre-eclampsia using individual participant data (IPD) from UK studies, to evaluate whether any of the models can accurately predict the condition when used within the UK healthcare setting. METHODS: IPD from 11 UK cohort studies (217,415 pregnant women) within the International Prediction of Pregnancy Complications (IPPIC) pre-eclampsia network contributed to external validation of published prediction models, identified by systematic review. Cohorts that measured all predictor variables in at least one of the identified models and reported pre-eclampsia as an outcome were included for validation. We reported the model predictive performance as discrimination (C-statistic), calibration (calibration plots, calibration slope, calibration-in-the-large), and net benefit. Performance measures were estimated separately in each available study and then, where possible, combined across studies in a random-effects meta-analysis. RESULTS: Of 131 published models, 67 provided the full model equation and 24 could be validated in 11 UK cohorts. Most of the models showed modest discrimination with summary C-statistics between 0.6 and 0.7. The calibration of the predicted compared to observed risk was generally poor for most models with observed calibration slopes less than 1, indicating that predictions were generally too extreme, although confidence intervals were wide. There was large between-study heterogeneity in each model's calibration-in-the-large, suggesting poor calibration of the predicted overall risk across populations. In a subset of models, the net benefit of using the models to inform clinical decisions appeared small and limited to probability thresholds between 5 and 7%. CONCLUSIONS: The evaluated models had modest predictive performance, with key limitations such as poor calibration (likely due to overfitting in the original development datasets), substantial heterogeneity, and small net benefit across settings. The evidence to support the use of these prediction models for pre-eclampsia in clinical decision-making is limited. Any models that we could not validate should be examined in terms of their predictive performance, net benefit, and heterogeneity across multiple UK settings before consideration for use in practice. TRIAL REGISTRATION: PROSPERO ID: CRD42015029349 .

3.
J Perinat Med ; 2020 Nov 05.
Artigo em Inglês | MEDLINE | ID: mdl-33155996

RESUMO

Objectives Discussing the individual probability of a successful vaginal birth after caesarean (VBAC) can support decision making. The aim of this study is to externally validate a prediction model for the probability of a VBAC in a Dutch population. Methods In this prospective cohort study in 12 Dutch hospitals, 586 women intending VBAC were included. Inclusion criteria were singleton pregnancies with a cephalic foetal presentation, delivery after 37 weeks and one previous caesarean section (CS) and preference for intending VBAC. The studied prediction model included six predictors: pre-pregnancy body mass index, previous vaginal delivery, previous CS because of non-progressive labour, Caucasian ethnicity, induction of current labour, and estimated foetal weight ≥90th percentile. The discriminative and predictive performance of the model was assessed using receiver operating characteristic curve analysis and calibration plots. Results The area under the curve was 0.73 (CI 0.69-0.78). The average predicted probability of a VBAC according to the prediction model was 70.3% (range 33-92%). The actual VBAC rate was 71.7%. The calibration plot shows some overestimation for low probabilities of VBAC and an underestimation of high probabilities. Conclusions The prediction model showed good performance and was externally validated in a Dutch population. Hence it can be implemented as part of counselling for mode of delivery in women choosing between intended VBAC or planned CS after previous CS.

5.
BMJ ; 369: m1328, 2020 04 07.
Artigo em Inglês | MEDLINE | ID: mdl-32265220

RESUMO

OBJECTIVE: To review and critically appraise published and preprint reports of prediction models for diagnosing coronavirus disease 2019 (covid-19) in patients with suspected infection, for prognosis of patients with covid-19, and for detecting people in the general population at increased risk of becoming infected with covid-19 or being admitted to hospital with the disease. DESIGN: Living systematic review and critical appraisal by the COVID-PRECISE (Precise Risk Estimation to optimise covid-19 Care for Infected or Suspected patients in diverse sEttings) group. DATA SOURCES: PubMed and Embase through Ovid, arXiv, medRxiv, and bioRxiv up to 5 May 2020. STUDY SELECTION: Studies that developed or validated a multivariable covid-19 related prediction model. DATA EXTRACTION: At least two authors independently extracted data using the CHARMS (critical appraisal and data extraction for systematic reviews of prediction modelling studies) checklist; risk of bias was assessed using PROBAST (prediction model risk of bias assessment tool). RESULTS: 14 217 titles were screened, and 107 studies describing 145 prediction models were included. The review identified four models for identifying people at risk in the general population; 91 diagnostic models for detecting covid-19 (60 were based on medical imaging, nine to diagnose disease severity); and 50 prognostic models for predicting mortality risk, progression to severe disease, intensive care unit admission, ventilation, intubation, or length of hospital stay. The most frequently reported predictors of diagnosis and prognosis of covid-19 are age, body temperature, lymphocyte count, and lung imaging features. Flu-like symptoms and neutrophil count are frequently predictive in diagnostic models, while comorbidities, sex, C reactive protein, and creatinine are frequent prognostic factors. C index estimates ranged from 0.73 to 0.81 in prediction models for the general population, from 0.65 to more than 0.99 in diagnostic models, and from 0.68 to 0.99 in prognostic models. All models were rated at high risk of bias, mostly because of non-representative selection of control patients, exclusion of patients who had not experienced the event of interest by the end of the study, high risk of model overfitting, and vague reporting. Most reports did not include any description of the study population or intended use of the models, and calibration of the model predictions was rarely assessed. CONCLUSION: Prediction models for covid-19 are quickly entering the academic literature to support medical decision making at a time when they are urgently needed. This review indicates that proposed models are poorly reported, at high risk of bias, and their reported performance is probably optimistic. Hence, we do not recommend any of these reported prediction models for use in current practice. Immediate sharing of well documented individual participant data from covid-19 studies and collaboration are urgently needed to develop more rigorous prediction models, and validate promising ones. The predictors identified in included models should be considered as candidate predictors for new models. Methodological guidance should be followed because unreliable predictions could cause more harm than benefit in guiding clinical decisions. Finally, studies should adhere to the TRIPOD (transparent reporting of a multivariable prediction model for individual prognosis or diagnosis) reporting guideline. SYSTEMATIC REVIEW REGISTRATION: Protocol https://osf.io/ehc47/, registration https://osf.io/wy245. READERS' NOTE: This article is a living systematic review that will be updated to reflect emerging evidence. Updates may occur for up to two years from the date of original publication. This version is update 2 of the original article published on 7 April 2020 (BMJ 2020;369:m1328), and previous updates can be found as data supplements (https://www.bmj.com/content/369/bmj.m1328/related#datasupp).


Assuntos
Infecções por Coronavirus/diagnóstico , Modelos Teóricos , Pneumonia Viral/diagnóstico , Coronavirus , Progressão da Doença , Hospitalização/estatística & dados numéricos , Humanos , Análise Multivariada , Pandemias , Prognóstico
6.
Am J Obstet Gynecol ; 223(3): 431.e1-431.e18, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32112732

RESUMO

BACKGROUND: Obstetric health care relies on an adequate antepartum risk selection. Most guidelines used for risk stratification, however, do not assess absolute risks. In 2017, a prediction tool was implemented in a Dutch region. This tool combines first trimester prediction models with obstetric care paths tailored to the individual risk profile, enabling risk-based care. OBJECTIVE: To assess impact and cost-effectiveness of risk-based care compared to care-as-usual in a general population. METHODS: A before-after study was conducted using 2 multicenter prospective cohorts. The first cohort (2013-2015) received care-as-usual; the second cohort (2017-2018) received risk-based care. Health outcomes were (1) a composite of adverse perinatal outcomes and (2) maternal quality-adjusted life-years. Costs were estimated using a health care perspective from conception to 6 weeks after the due date. Mean costs per woman, cost differences between the 2 groups, and incremental cost effectiveness ratios were calculated. Sensitivity analyses were performed to evaluate the robustness of the findings. RESULTS: In total 3425 women were included. In nulliparous women there was a significant reduction of perinatal adverse outcomes among the risk-based care group (adjusted odds ratio, 0.56; 95% confidence interval, 0.32-0.94), but not in multiparous women. Mean costs per pregnant woman were significantly lower for risk-based care (mean difference, -€2766; 95% confidence interval, -€3700 to -€1825). No differences in maternal quality of life, adjusted for baseline health, were observed. CONCLUSION: In the Netherlands, risk-based care in nulliparous women was associated with improved perinatal outcomes as compared to care-as-usual. Furthermore, risk-based care was cost-effective compared to care-as-usual and resulted in lower health care costs.


Assuntos
Obstetrícia , Padrões de Prática Médica , Cuidado Pré-Natal/economia , Adolescente , Adulto , Estudos de Coortes , Análise Custo-Benefício , Feminino , Humanos , Pessoa de Meia-Idade , Países Baixos , Gravidez , Primeiro Trimestre da Gravidez , Estudos Prospectivos , Anos de Vida Ajustados por Qualidade de Vida , Adulto Jovem
7.
BMC Med Inform Decis Mak ; 20(1): 54, 2020 03 12.
Artigo em Inglês | MEDLINE | ID: mdl-32164641

RESUMO

BACKGROUND: Many colorectal cancer (CRC) survivors experience persisting health problems post-treatment that compromise their health-related quality of life (HRQoL). Prediction models are useful tools for identifying survivors at risk of low HRQoL in the future and for taking preventive action. Therefore, we developed prediction models for CRC survivors to estimate the 1-year risk of low HRQoL in multiple domains. METHODS: In 1458 CRC survivors, seven HRQoL domains (EORTC QLQ-C30: global QoL; cognitive, emotional, physical, role, social functioning; fatigue) were measured prospectively at study baseline and 1 year later. For each HRQoL domain, scores at 1-year follow-up were dichotomized into low versus normal/high. Separate multivariable logistic prediction models including biopsychosocial predictors measured at baseline were developed for the seven HRQoL domains, and internally validated using bootstrapping. RESULTS: Average time since diagnosis was 5 years at study baseline. Prediction models included both non-modifiable predictors (age, sex, socio-economic status, time since diagnosis, tumor stage, chemotherapy, radiotherapy, stoma, micturition, chemotherapy-related, stoma-related and gastrointestinal complaints, comorbidities, social inhibition/negative affectivity, and working status) and modifiable predictors (body mass index, physical activity, smoking, meat consumption, anxiety/depression, pain, and baseline fatigue and HRQoL scores). Internally validated models showed good calibration and discrimination (AUCs: 0.83-0.93). CONCLUSIONS: The prediction models performed well for estimating 1-year risk of low HRQoL in seven domains. External validation is needed before models can be applied in practice.


Assuntos
Sobreviventes de Câncer/estatística & dados numéricos , Neoplasias Colorretais/epidemiologia , Modelos Estatísticos , Qualidade de Vida , Idoso , Neoplasias Colorretais/fisiopatologia , Comorbidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Risco
8.
Acta Obstet Gynecol Scand ; 99(7): 891-900, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31955406

RESUMO

INTRODUCTION: We performed an independent validation study of all published first trimester prediction models, containing non-invasive predictors, for the risk of gestational diabetes mellitus. Furthermore, the clinical potential of the best performing models was evaluated. MATERIAL AND METHODS: Systemically selected prediction models from the literature were validated in a Dutch prospective cohort using data from Expect Study I and PRIDE Study. The predictive performance of the models was evaluated by discrimination and calibration. Clinical utility was assessed using decision curve analysis. Screening performance measures were calculated at different risk thresholds for the best model and compared with current selective screening strategies. RESULTS: The validation cohort included 5260 women. Gestational diabetes mellitus was diagnosed in 127 women (2.4%). The discriminative performance of the 12 included models ranged from 68% to 75%. Nearly all models overestimated the risk. After recalibration, agreement between the observed outcomes and predicted probabilities improved for most models. CONCLUSIONS: The best performing prediction models showed acceptable performance measures and may enable more personalized medicine-based antenatal care for women at risk of developing gestational diabetes mellitus compared with current applied strategies.


Assuntos
Algoritmos , Diabetes Gestacional/diagnóstico , Adulto , Feminino , Humanos , Modelos Estatísticos , Países Baixos , Valor Preditivo dos Testes , Gravidez , Probabilidade , Prognóstico , Estudos Prospectivos , Medição de Risco , Fatores de Risco
9.
Acta Obstet Gynecol Scand ; 99(7): 875-883, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31953956

RESUMO

INTRODUCTION: Low-dose aspirin (LDA) prophylaxis has been shown to reduce women's preeclampsia risk. Evidence regarding LDA adherence rates of pregnant women is based almost exclusively on clinical trials, giving a potentially biased picture. Moreover, these studies do not report on determinants of adherence. Since 2017, obstetric healthcare professionals in a Dutch region have assessed women's preeclampsia risk by means of a prediction tool and counseled those with an above-population average risk on LDA as a prophylactic measure. MATERIAL AND METHODS: From 2017 to 2018, 865 women were recruited in multiple centers and prospectively followed using web-based surveys (Expect Study II). Rates and determinants of LDA usage among women with an increased preeclampsia risk in daily practice were assessed. Results were compared with findings in a similar cohort from a care-as-usual setting lacking risk-based counseling (Expect Study I, n = 2614). Netherlands Trial Register NTR4143. RESULTS: In total, 306 women had a predicted increased preeclampsia risk. LDA usage was higher for women receiving risk-based care than care-as-usual (29.4% vs 1.5%, odds ratio 19.1, 95% confidence interval 11.2-32.5). Daily LDA usage was positively correlated with both predicted risk and women's concerns regarding preeclampsia. Most reported reasons for non- or incomplete use were unawareness of LDA as a preventive intervention, concerns about potential adverse effects and doubts regarding the benefits. CONCLUSIONS: Risk-based counseling was associated with a higher prevalence of LDA usage, but general usage rates were low. Future research regarding potential factors improving the usage of LDA during pregnancy is necessary.


Assuntos
Aspirina/administração & dosagem , Inibidores da Agregação de Plaquetas/administração & dosagem , Pré-Eclâmpsia/prevenção & controle , Adulto , Aconselhamento , Feminino , Humanos , Adesão à Medicação , Países Baixos , Gravidez , Resultado da Gravidez , Estudos Prospectivos , Medição de Risco , Fatores de Risco
10.
J Psychosom Obstet Gynaecol ; : 1-9, 2020 Jan 08.
Artigo em Inglês | MEDLINE | ID: mdl-31913725

RESUMO

Background: Satisfaction of pregnancy and childbirth is an important quality measure of maternity care. Satisfaction questionnaires generally result in high scores. However, it has been argued that dissatisfaction relies on a different construct. In response to a worldwide call for obstetric care that is more woman-centered, we identified and described the contributors to suboptimal satisfaction with pregnancy and childbirth.Methods: A prospective subcohort of 739 women from a larger cohort (Expect Study I, n = 2614) received a pregnancy and childbirth satisfaction questionnaire. Scores were transformed to a binary outcome whereby a score <100 points corresponded with less satisfied women. We performed a multiple logistic regression analysis to define independent perinatal factors related to suboptimal satisfaction.Results: Decreased perceived personal well-being, antenatal anxiety, and obstetrician-led care during labor were all independently associated with suboptimal pregnancy and childbirth satisfaction. No difference in satisfaction was found between antenatal care led by a midwife or an obstetrician, but midwife-led antenatal care reduced the odds of suboptimal satisfaction compared to women who were transferred to an obstetrician in the antenatal period. Antenatal anxiety was experienced by 25% of all women and is associated with decreased satisfaction scores.Discussion: Screening and treatment of women suffering from anxiety might improve pregnancy and childbirth satisfaction, but further research is necessary. Women's birthing experience may improve by reducing unnecessary secondary obstetric care.

11.
Eur J Nutr ; 59(1): 167-174, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30661104

RESUMO

PURPOSE: Adequate calcium intake during pregnancy is of major importance for the health of both mother and fetus. Up to date, evidence on the prevalence of inadequate calcium intake among pregnant women is sparse for Western countries, and it is unknown to what extent inadequate dietary calcium intake is adequately balanced by supplement use. The objective of this study was to estimate calcium intake from diet and supplement use during the early pregnancy in The Netherlands. METHODS: As part of the Expect cohort study, 2477 pregnant women (8-16 weeks of gestation) completed an online questionnaire including questions on baseline characteristics, the use of calcium containing supplements, and a short food-frequency questionnaire (FFQ). Intake data were used to calculate median calcium intakes from diet, from supplements, and combined, and to compare these values with currently accepted requirement levels. RESULTS: Forty-two percent of the pregnant women had a total calcium intake below the estimated average requirement of 800 mg/day. Median (interquartile range) calcium intake was 886 (611-1213) mg/day. Calcium or multivitamin supplements were used by 64.8% of the women at 8 weeks of gestation, with a median calcium content of 120.0 (60.0-200.0) mg/day. Prenatal vitamins were the most often used supplements (60.6%). CONCLUSIONS: Forty-two percent of Dutch pregnant women have an inadequate calcium intake. Supplements are frequently used, but most do not contain sufficient amounts to correct this inadequate intake.


Assuntos
Cálcio na Dieta/administração & dosagem , Cálcio/deficiência , Dieta/estatística & dados numéricos , Suplementos Nutricionais , Complicações na Gravidez/epidemiologia , Adolescente , Adulto , Estudos de Coortes , Dieta/métodos , Feminino , Humanos , Países Baixos/epidemiologia , Gravidez , Estudos Prospectivos , Inquéritos e Questionários , Adulto Jovem
12.
Med Decis Making ; 40(1): 81-89, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31789093

RESUMO

Background. Despite improved management, preeclampsia remains an important cause of maternal and neonatal mortality and morbidity. Low-dose aspirin (LDA) lowers the risk of preeclampsia. Although several guidelines recommend LDA prophylaxis in women at increased risk, they disagree about the definition of high risk. Recently, an externally validated prediction model for preeclampsia was implemented in a Dutch region combined with risk-based obstetric care paths. Objectives. To demonstrate the selection of a risk threshold and to evaluate the adherence of obstetric health care professionals to the prediction tool. Study Design. Using a survey (n = 136) and structured meetings among health care professionals, possible cutoff values at which LDA should be discussed were proposed. The prediction model, with chosen cutoff and corresponding risk-based care paths, was embedded in an online tool. Subsequently, a prospective multicenter cohort study (n = 850) was performed to analyze the adherence of health care professionals. Patient questionnaires, linked to the individual risk profiles calculated by the online tool, were used to evaluate adherence. Results. Health care professionals agreed upon employing a tool with a high detection rate (cutoff: 3.0%; sensitivity 75%, specificity 64%) followed by shared decision between patients and health care professionals on LDA prophylaxis. Of the 850 enrolled women, 364 women had an increased risk of preeclampsia. LDA was discussed with 273 of these women, resulting in an 81% adherence rate. Conclusion. Consensus regarding a suitable risk cutoff threshold was reached. The adherence to this recommendation was 81%, indicating adequate implementation.


Assuntos
Fidelidade a Diretrizes/normas , Pessoal de Saúde/normas , Pré-Eclâmpsia/diagnóstico , Adulto , Aspirina/uso terapêutico , Regras de Decisão Clínica , Estudos de Coortes , Feminino , Fidelidade a Diretrizes/estatística & dados numéricos , Pessoal de Saúde/psicologia , Pessoal de Saúde/estatística & dados numéricos , Humanos , Países Baixos , Gravidez , Estudos Prospectivos , Fatores de Risco , Inquéritos e Questionários
13.
Reprod Biomed Online ; 39(2): 262-268, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31182355

RESUMO

RESEARCH QUESTION: Does intrauterine insemination (IUI) carried out simultaneously with HCG triggering ('simultaneous IUI') increase the ongoing pregnancy rate compared with IUI 32-36 h after HCG triggering ('regular IUI')? STUDY DESIGN: An open-label randomized clinical trial was conducted in seven Dutch fertility clinics. One hundred and sixty-six couples were randomized to receive simultaneous IUI and 208 couples to receive regular IUI. Treatment was allocated using a computer-based randomization algorithm using sealed opaque envelopes. Data were analysed according to the intention-to-treat principle. Couples with unexplained or mild-to-moderate male factor subfertility were eligible. Exclusion criteria were female age 42 years or older, female body mass index 35 kg/m2 or over, double-sided tubal pathology or severe male factor subfertility. Mild ovarian stimulation was carried out by subcutaneous FSH self-administration. 'Simultaneous IUI' was carried out at the point of HCG triggering for ovulation. 'Regular IUI' was carried out 32-36 h after HCG triggering. RESULTS: The cumulative ongoing pregnancy rate after a maximum of four cycles was 26.2% for simultaneous IUI (43 ongoing pregnancies) and 33.7% for regular IUI (70 ongoing pregnancies) (RR 0.78 95% CI 0.57 to 1.07). Ongoing pregnancy rates per cycle in the simultaneous IUI group were 6.8%, 10.5%, 9.5% and 7.4% for the first, second, third and fourth IUI cycle. In the regular IUI group, ongoing pregnancy rates were 8.3%, 16.4%, 13.5% and 9.0% for the first, second, third and fourth IUI cycle. CONCLUSIONS: This multicentre randomized controlled trial did not demonstrate that IUI carried out at the point of HCG triggering increases pregnancy rates compared with IUI carried out around the time of ovulation.


Assuntos
Gonadotropina Coriônica/administração & dosagem , Inseminação Artificial/métodos , Adulto , Feminino , Hormônio Foliculoestimulante/metabolismo , Humanos , Infertilidade Feminina/terapia , Infertilidade Masculina/terapia , Masculino , Países Baixos , Indução da Ovulação , Gravidez , Resultado da Gravidez , Taxa de Gravidez , Fatores de Tempo
14.
J Nutr ; 149(1): 131-138, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30544236

RESUMO

Background: The effect of vitamin B-12 from different animal foods on vitamin B-12 biomarker status has not previously been evaluated in pregnant women. Objective: We examined the association of vitamin B-12 intake from dairy, meat, fish (including shellfish), and eggs with circulating concentrations of vitamin B-12 biomarkers and with the presence of vitamin B-12 deficiency in 1266 pregnant women participating in the KOALA Birth Cohort Study. Methods: Blood samples were collected in weeks 34-36 of pregnancy, and vitamin B-12 intake from foods and supplements was estimated with a semiquantitative food-frequency questionnaire (FFQ). Total vitamin B-12, holotranscobalamin (holoTC), and methylmalonic acid (MMA) were determined in plasma. Vitamin B-12 deficiency was defined as holoTC <35 pmol/L and MMA >0.45 µmol/L. Associations were evaluated with linear and logistic regression analyses, adjusting for potential confounders. Results: Significant dose-response relations were observed between vitamin B-12 intake from dairy, meat, and fish and plasma vitamin B-12, holoTC, and MMA [P-trend for (shell)fish with MMA = 0.002; P-trend for dairy, meat, and fish with all other markers < 0.001]. The OR (95% CI) of vitamin B-12 deficiency in the third compared with the first tertile of dairy-derived vitamin B-12 was 0.13 (0.04, 0.49), and the ORs for vitamin B-12 from meat and fish were 0.33 (0.11, 0.97) and 0.25 (0.08, 0.82), respectively. Egg-derived vitamin B-12 was only associated with holoTC. Additional analyses showed that self-defined vegetarians and FFQ-defined lacto-ovo-vegetarians had lower median total dietary vitamin B-12 intake and considerably worse vitamin B-12 biomarker status than omnivores and pescatarians. Conclusions: In pregnant Dutch women, higher intakes of vitamin B-12 from dairy, meat, and fish were positively associated with vitamin B-12 status, suggesting that dairy, meat, and fish are good sources of bioactive vitamin B-12 in pregnancy. Nevertheless, for (lacto-)vegetarians, vitamin B-12 supplementation is recommended.


Assuntos
Laticínios , Peixes , Carne , Frutos do Mar , Vitamina B 12/administração & dosagem , Adulto , Animais , Biomarcadores/sangue , Estudos de Coortes , Estudos Transversais , Dieta , Registros de Dieta , Feminino , Análise de Alimentos , Humanos , Estado Nutricional , Gravidez
15.
Fetal Diagn Ther ; 45(6): 381-393, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30021205

RESUMO

INTRODUCTION: This study assessed the external validity of all published first trimester prediction models for the risk of preeclampsia (PE) based on routinely collected maternal predictors. Moreover, the potential utility of the best-performing models in clinical practice was evaluated. MATERIAL AND METHODS: Ten prediction models were systematically selected from the literature. We performed a multicenter prospective cohort study in the Netherlands between July 1, 2013, and December 31, 2015. Eligible pregnant women completed a web-based questionnaire before 16 weeks' gestation. The outcome PE was established using postpartum questionnaires and medical records. Predictive performance of each model was assessed by means of discrimination (c-statistic) and a calibration plot. Clinical usefulness was evaluated by means of decision curve analysis and by calculating the potential impact at different risk thresholds. RESULTS: The validation cohort contained 2,614 women of whom 76 developed PE (2.9%). Five models showed moderate discriminative performance with c-statistics ranging from 0.73 to 0.77. Adequate calibration was obtained after refitting. The best models were clinically useful over a small range of predicted probabilities. DISCUSSION: Five of the ten included first trimester prediction models for PE showed moderate predictive performance. The best models may provide more benefit compared to risk selection as used in current guidelines.


Assuntos
Pré-Eclâmpsia/diagnóstico , Estudos de Coortes , Feminino , Indicadores Básicos de Saúde , Humanos , Modelos Estatísticos , Pré-Eclâmpsia/prevenção & controle , Gravidez , Primeiro Trimestre da Gravidez
16.
Br J Cancer ; 119: 357-363, 2018 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-29937543

RESUMO

BACKGROUND: The effect of in vitro fertilisation (IVF) on breast cancer risk for BRCA1/2 mutation carriers is rarely examined. As carriers may increasingly undergo IVF as part of preimplantation genetic diagnosis (PGD), we examined the impact of ovarian stimulation for IVF on breast cancer risk in BRCA1/2 mutation carriers. METHODS: The study population consisted of 1550 BRCA1 and 964 BRCA2 mutation carriers, derived from the nationwide HEBON study and the nationwide PGD registry. Questionnaires, clinical records and linkages with the Netherlands Cancer Registry were used to collect data on IVF exposure, risk-reducing surgeries and cancer diagnosis, respectively. Time-dependent Cox regression analyses were conducted, stratified for birth cohort and adjusted for subfertility. RESULTS: Of the 2514 BRCA1/2 mutation carriers, 3% (n = 76) were exposed to ovarian stimulation for IVF. In total, 938 BRCA1/2 mutation carriers (37.3%) were diagnosed with breast cancer. IVF exposure was not associated with risk of breast cancer (HR: 0.79, 95% CI: 0.46-1.36). Similar results were found for the subgroups of subfertile women (n = 232; HR: 0.73, 95% CI: 0.39-1.37) and BRCA1 mutation carriers (HR: 1.12, 95% CI: 0.60-2.09). In addition, age at and recency of first IVF treatment were not associated with breast cancer risk. CONCLUSION: No evidence was found for an association between ovarian stimulation for IVF and breast cancer risk in BRCA1/2 mutation carriers.


Assuntos
Neoplasias da Mama/etiologia , Fertilização In Vitro/efeitos adversos , Genes BRCA1 , Genes BRCA2 , Heterozigoto , Mutação , Indução da Ovulação , Adulto , Idoso , Neoplasias da Mama/genética , Feminino , Humanos , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Risco
17.
Acta Obstet Gynecol Scand ; 97(8): 907-920, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29663314

RESUMO

INTRODUCTION: Prediction models may contribute to personalized risk-based management of women at high risk of spontaneous preterm delivery. Although prediction models are published frequently, often with promising results, external validation generally is lacking. We performed a systematic review of prediction models for the risk of spontaneous preterm birth based on routine clinical parameters. Additionally, we externally validated and evaluated the clinical potential of the models. MATERIAL AND METHODS: Prediction models based on routinely collected maternal parameters obtainable during first 16 weeks of gestation were eligible for selection. Risk of bias was assessed according to the CHARMS guidelines. We validated the selected models in a Dutch multicenter prospective cohort study comprising 2614 unselected pregnant women. Information on predictors was obtained by a web-based questionnaire. Predictive performance of the models was quantified by the area under the receiver operating characteristic curve (AUC) and calibration plots for the outcomes spontaneous preterm birth <37 weeks and <34 weeks of gestation. Clinical value was evaluated by means of decision curve analysis and calculating classification accuracy for different risk thresholds. RESULTS: Four studies describing five prediction models fulfilled the eligibility criteria. Risk of bias assessment revealed a moderate to high risk of bias in three studies. The AUC of the models ranged from 0.54 to 0.67 and from 0.56 to 0.70 for the outcomes spontaneous preterm birth <37 weeks and <34 weeks of gestation, respectively. A subanalysis showed that the models discriminated poorly (AUC 0.51-0.56) for nulliparous women. Although we recalibrated the models, two models retained evidence of overfitting. The decision curve analysis showed low clinical benefit for the best performing models. CONCLUSIONS: This review revealed several reporting and methodological shortcomings of published prediction models for spontaneous preterm birth. Our external validation study indicated that none of the models had the ability to predict spontaneous preterm birth adequately in our population. Further improvement of prediction models, using recent knowledge about both model development and potential risk factors, is necessary to provide an added value in personalized risk assessment of spontaneous preterm birth.

18.
Matern Child Nutr ; 14(1)2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-28626878

RESUMO

Adequate calcium intake during pregnancy is important in the prevention of pre-eclampsia. A substantial proportion of pregnant women do not meet the recommended daily calcium intake, even in developed countries. Nonetheless, calcium supplementation is not routinely advised to pregnant women in most countries. We aimed to predict the impact of advising pregnant women to use calcium supplements (1,000 mg/day) on the number of cases of pre-eclampsia prevented and related health care costs. By use of a decision-analytic model, we assessed the expected impact of advising calcium supplementation to either (1) all pregnant women, (2) women at high risk of developing pre-eclampsia, or (3) women with a low dietary calcium intake compared with current care. Calculations were performed for a hypothetical cohort of 100,000 pregnant women living in a high-income country, although input parameters of the model can be adjusted so as to fit other settings. The incidence of pre-eclampsia could be reduced by 25%, 8%, or 13% when advising calcium supplementation to all pregnant women, women at high risk of pre-eclampsia, or women with a low dietary calcium intake, respectively. Expected net financial benefits of the three scenarios were of €4,621,465, €2,059,165, or €2,822,115 per 100,000 pregnant women, respectively. Advising pregnant women to use calcium supplements can be expected to cause substantial reductions in the incidence of pre-eclampsia as well as related health care costs. It appears most efficient to advise calcium supplementation to all pregnant women, not subgroups only.


Assuntos
Cálcio na Dieta/uso terapêutico , Suplementos Nutricionais , Medicina Baseada em Evidências , Fenômenos Fisiológicos da Nutrição Materna , Modelos Econômicos , Guias de Prática Clínica como Assunto , Pré-Eclâmpsia/prevenção & controle , Adulto , Cálcio/deficiência , Cálcio na Dieta/efeitos adversos , Cálcio na Dieta/economia , Terapia Combinada/economia , Redução de Custos , Custos e Análise de Custo , Técnicas de Apoio para a Decisão , Deficiências Nutricionais/economia , Deficiências Nutricionais/epidemiologia , Deficiências Nutricionais/fisiopatologia , Deficiências Nutricionais/prevenção & controle , Países Desenvolvidos , Suplementos Nutricionais/efeitos adversos , Suplementos Nutricionais/economia , Medicina Baseada em Evidências/economia , Feminino , Custos Hospitalares , Humanos , Incidência , Educação de Pacientes como Assunto/economia , Pré-Eclâmpsia/economia , Pré-Eclâmpsia/etiologia , Pré-Eclâmpsia/terapia , Gravidez , Complicações na Gravidez/economia , Complicações na Gravidez/epidemiologia , Complicações na Gravidez/fisiopatologia , Complicações na Gravidez/prevenção & controle , Risco
20.
Hum Pathol ; 59: 62-69, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27697590

RESUMO

This study aims to develop a prediction model for spontaneous regression of cervical intraepithelial neoplasia grade 2 (CIN 2) lesions based on simple clinicopathological parameters. The study was conducted at Maastricht University Medical Center, the Netherlands. The prediction model was developed in a retrospective cohort of 129 women with a histologic diagnosis of CIN 2 who were managed by watchful waiting for 6 to 24months. Five potential predictors for spontaneous regression were selected based on the literature and expert opinion and were analyzed in a multivariable logistic regression model, followed by backward stepwise deletion based on the Wald test. The prediction model was internally validated by the bootstrapping method. Discriminative capacity and accuracy were tested by assessing the area under the receiver operating characteristic curve (AUC) and a calibration plot. Disease regression within 24months was seen in 91 (71%) of 129 patients. A prediction model was developed including the following variables: smoking, Papanicolaou test outcome before the CIN 2 diagnosis, concomitant CIN 1 diagnosis in the same biopsy, and more than 1 biopsy containing CIN 2. Not smoking, Papanicolaou class <3, concomitant CIN 1, and no more than 1 biopsy containing CIN 2 were predictive of disease regression. The AUC was 69.2% (95% confidence interval, 58.5%-79.9%), indicating a moderate discriminative ability of the model. The calibration plot indicated good calibration of the predicted probabilities. This prediction model for spontaneous regression of CIN 2 may aid physicians in the personalized management of these lesions.


Assuntos
Neoplasia Intraepitelial Cervical/patologia , Técnicas de Apoio para a Decisão , Regressão Neoplásica Espontânea , Neoplasias do Colo do Útero/patologia , Centros Médicos Acadêmicos , Adolescente , Adulto , Idoso , Área Sob a Curva , Biópsia , Neoplasia Intraepitelial Cervical/etiologia , Colposcopia , Feminino , Humanos , Modelos Logísticos , Pessoa de Meia-Idade , Análise Multivariada , Gradação de Tumores , Países Baixos , Teste de Papanicolaou , Valor Preditivo dos Testes , Curva ROC , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de Risco , Fumar/efeitos adversos , Fatores de Tempo , Neoplasias do Colo do Útero/etiologia , Adulto Jovem
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