Prenatal Weight Change Trajectories and Perinatal Outcomes among Twin Gestations.

OBJECTIVE: Despite an increase in twin pregnancies in recent decades, the Institute of Medicine twin weight gain recommendations remain provisional and provide no guidance for the pattern or timing of weight change. We sought to characterize gestational weight change trajectory patterns and examine associations with birth outcomes in a cohort of twin pregnancies. STUDY DESIGN: Prenatal and delivery records were examined for 320 twin pregnancies from a maternal-fetal medicine practice in Austin, TX 2011-2019. Prenatal weights for those with >1 measured weight in the first trimester and ≥3 prenatal weights were included in analyses. Trajectories were estimated to 32 weeks (mean delivery: 33.7 ± 3.3 weeks) using flexible latent class mixed models with low-rank thin-plate splines. Associations between trajectory classes and infant outcomes were analyzed using multivariable Poisson or linear regression. RESULTS: Weight change from prepregnancy to delivery was 15.4 ± 6.3 kg for people with an underweight body mass index, 15.4 ± 5.8 kg for healthy weight, 14.7 ± 6.9 kg for overweight, and 12.5 ± 6.4 kg for obesity. Three trajectory classes were identified: low (Class 1), moderate (Class 2), or high gain (Class 3). Class 1 (24.7%) maintained weight for 15 weeks and then gained an estimated 6.6 kg at 32 weeks. Class 2 (60.9%) exhibited steady gain with 13.5 kg predicted total gain, and Class 3 (14.4%) showed rapid gain across pregnancy with 21.3 kg predicted gain. Compared to Class 1, Class 3 was associated with higher birth weight z-score (ß = 0.63, 95% confidence interval [CI]: 0.31,0.96), increased risk for large for gestational age (IRR = 5.60, 95% CI: 1.59, 19.67), and birth <32 weeks (IRR = 2.44, 95%CI: 1.10, 5.4) that was attenuated in sensitivity analyses. Class 2 was associated with moderately elevated birth weight z-score (ß = 0.24, 95%CI: 0.00, 0.48, p = 0.050). CONCLUSION: Gestational weight change followed a low, moderate, or high trajectory; both moderate and high gain patterns were associated with increased infant size outcomes. Optimal patterns of weight change that balance risk during the prenatal, perinatal, and neonatal periods require further investigation, particularly in high-risk twin pregnancies. KEY POINTS: · A majority gained weight below IOM twin recommendations.. · Three patterns of GWC across pregnancy were identified.. · Moderate or high GWC was associated with infant size..

Combined impact of Medicare's hospital pay for performance programs on quality and safety outcomes is mixed.

BACKGROUND: Three major hospital pay for performance (P4P) programs were introduced by the Affordable Care Act and intended to improve the quality, safety and efficiency of care provided to Medicare beneficiaries. The financial risk to hospitals associated with Medicare's P4P programs is substantial. Evidence on the positive impact of these programs, however, has been mixed, and no study has assessed their combined impact. In this study, we examined the combined impact of Medicare's P4P programs on clinical areas and populations targeted by the programs, as well as those outside their focus. METHODS: We used 2007-2016 Healthcare Cost and Utilization Project State Inpatient Databases for 14 states to identify hospital-level inpatient quality indicators (IQIs) and patient safety indicators (PSIs), by quarter and payer (Medicare vs. non-Medicare). IQIs and PSIs are standardized, evidence-based measures that can be used to track hospital quality of care and patient safety over time using hospital administrative data. The study period of 2007-2016 was selected to capture multiple years before and after introduction of program metrics. Interrupted time series was used to analyze the impact of the P4P programs on study outcomes targeted and not targeted by the programs. In sensitivity analyses, we examined the impact of these programs on care for non-Medicare patients. RESULTS: Medicare P4P programs were not associated with consistent improvements in targeted or non-targeted quality and safety measures. Moreover, mortality rates across targeted and untargeted conditions were generally getting worse after the introduction of Medicare's P4P programs. Trends in PSIs were extremely mixed, with five outcomes trending in an expected (improving) direction, five trending in an unexpected (deteriorating) direction, and three with insignificant changes over time. Sensitivity analyses did not substantially alter these results. CONCLUSIONS: Consistent with previous studies for individual programs, we detect minimal, if any, effect of Medicare's hospital P4P programs on quality and safety. Given the growing evidence of limited impact, the administrative cost of monitoring and enforcing penalties, and potential increase in mortality, CMS should consider redesigning their P4P programs before continuing to expand them.

Shrinking lung syndrome complicating pediatric systemic lupus erythematosus.

Systemic lupus erythematosis (SLE) can affect the lungs and pleura, usually manifesting with pleural effusions or diffuse parenchymal disease. A rare manifestation of SLE is shrinking lung syndrome, a severe restrictive respiratory disorder. While pleuropulmonary complications of pediatric SLE are common, shrinking lung syndrome is exceedingly rare in children. We present a case of a 13-year-old girl previously diagnosed with lupus, who developed severe dyspnea on exertion and restrictive pulmonary physiology. Her chest radiographs on presentation demonstrated low lung volumes, and CT showed neither pleural nor parenchymal disease. Fluoroscopy demonstrated poor diaphragmatic excursion. While shrinking lung syndrome is described and studied in adults, there is only sparse reference to shrinking lung syndrome in children.

Postpartum Obesity Is Associated With Increases in Child Adiposity in Midchildhood in a Cohort of Black and Dominican Youth.

Background: Obesity disproportionately affects marginalized and low-income populations. Birth parent obesity from the prenatal period and childhood has been associated with child obesity. It is unknown whether prenatal or postnatal birth parent obesity has differential effects on subsequent changes in adiposity and metabolic health in children. Objectives: We evaluated how birth parent obesity 7 y after delivery was associated with child body composition changes and cardiometabolic health in midchildhood and further assessed the influence of the perinatal and postpartum period on associations. Methods: Black and Dominican pregnant individuals were enrolled, and dyads (n = 319) were followed up at child age 7 and 9 y. Measures included, height, weight, waist circumference (WC), and percent body fat (BF%). Multiple linear regression was used to relate postpartum weight status with child outcomes accounting for attrition, and a series of secondary analyses were conducted with additional adjustment for perinatal weight status, gestational weight gain (GWG), and/or long-term weight retention to evaluate how these factors influenced associations. Results: Almost one-quarter (23%) of birth parents and 24.1% children were classified with obesity at child age 7 y, while at 9 y, 30% of children had obesity. Birth parent obesity at child age 7 y was associated with greater changes, from ages 7 to 9 y, in child BMI z-score (ß: 0.13; 95% CI: 0.02, 0.24) and BF% (ß: 1.15; 95% CI: 0.22, 2.09) but not obesity at age 9 y. All observed associations crossed the null after additional adjustment for prenatal factors. Conclusions: Birth parent obesity at 7-y postpartum is associated with greater gains in child BMI z-score and BF% in midchildhood. These associations diminish after accounting for prenatal size, suggesting a lasting impact of the perinatal environment and that interventions supporting families from the prenatal period through childhood are needed.

Diagnostic imaging of fetal and pediatric orbital abnormalities.

OBJECTIVE: The orbit contains structures from which a wide spectrum of disease can arise. This article focuses on orbital anatomy and a simple compartmental approach to evaluating the orbit on diagnostic imaging. The characteristic findings of key fetal structural diseases and a wide spectrum of pediatric orbital disorders, including inflammatory disorders and developmental lesions, and the differential diagnosis of benign versus malignant masses will be discussed. CONCLUSION: Orbital abnormalities in fetuses may be recognized using ultrasound and MRI. Anophthalmia, hypertelorism, and hypotelorism either may be part of a genetic syndrome or may be related to a developmental abnormality of the fetal skull. In the pediatric population, cross-sectional imaging with CT and MRI offers a means to assess which compartments of the orbit are affected. Aggressive masses have characteristic features and must be evaluated for intracranial extension.

Novel approaches to examining weight changes in pregnancies affected by obesity.

BACKGROUND: Current gestational weight change (GWC) recommendations for obese individuals were established with limited evidence of the pattern and timing of weight change across pregnancy. Similarly, the recommendation of 5-9 kg does not differentiate by the severity of obesity. OBJECTIVES: We sought to describe GWC trajectory classes by obesity grade and associated infant outcomes among a large, diverse cohort. METHODS: The study population included 22,355 individuals with singleton pregnancies, obesity (BMI ≥30.0 kg/m2), and normal glucose tolerance who delivered at Kaiser Permanente Northern California between 2008 and 2013. Obesity grade-specific GWC trajectories were modeled at 38 wk using flexible latent class mixed modeling (package lcmm) in R. Multivariable Poisson or linear regression models estimated the associations between the GWC trajectory class and infant outcomes (size-for-gestational age and preterm birth) by obesity grade. RESULTS: Five GWC trajectory classes were identified for each obesity grade, each with a distinct pattern of weight change before 15 wk (including loss, stability, and gain) followed by weight gain thereafter (low, moderate, and high). Two classes with high overall gain were associated with an increased risk for large for gestational age (LGA) in obesity grade 1 (IRR = 1.27; 95% CI: 1.10, 1.46; IRR = 1.47; 95% CI: 1.24, 1.74). Both high (IRR = 2.02; 95% CI: 1.61, 2.52; IRR = 1.98; 95% CI: 1.52, 2.58) and 2 moderate-gain classes (IRR = 1.40; 95% CI 1.14, 1.71; IRR = 1.51; 95% CI: 1.20, 1.90) were associated with LGA in grade 2, and only early loss/late moderate-gain class 3 (IRR = 1.30; 95% CI: 1.04, 1.62) was associated in grade 3. This class was also associated with preterm birth in grade 2. No associations were detected between GWC and small for gestational age (SGA). CONCLUSIONS: Among the pregnancies affected by obesity, GWC was not linear or uniform. Different patterns of high gain were associated with an increased risk for LGA with the greatest magnitude in obesity grade 2, whereas GWC patterns were not associated with SGA.

Prenatal weight and regional body composition trajectories and neonatal body composition: The NICHD Foetal Growth Studies.

BACKGROUND: Gestational weight gain (GWG) and anthropometric trajectories may affect foetal programming and are potentially modifiable. OBJECTIVES: To assess concomitant patterns of change in weight, circumferences and adiposity across gestation as an integrated prenatal exposure, and determine how they relate to neonatal body composition. METHODS: Data are from a prospective cohort of singleton pregnancies (n = 2182) enrolled in United States perinatal centres, 2009-2013. Overall and by prepregnancy BMI group (overweight/obesity and healthy weight), joint latent trajectory models were fit with prenatal weight, mid-upper arm circumference (MUAC), triceps (TSF) and subscapular (SSF) skinfolds. Differences in neonatal body composition by trajectory class were assessed via weighted least squares. RESULTS: Six trajectory patterns reflecting co-occurring changes in weight and MUAC, SSF and TSF across pregnancy were identified overall and by body mass index (BMI) group. Among people with a healthy weight BMI, some differences were observed for neonatal subcutaneous adipose tissue, and among individuals with overweight/obesity some differences in neonatal lean mass were found. Neonatal adiposity measures were higher among infants born to individuals with prepregnancy overweight/obesity. CONCLUSIONS: Six integrated trajectory patterns of prenatal weight, subcutaneous adipose tissue and circumferences were observed that were minimally associated with neonatal body composition, suggesting a stronger influence of prepregnancy BMI.

Incidental myocardial infarct on conventional nongated CT: a review of the spectrum of findings with gated CT and cardiac MRI correlation.

OBJECTIVE: Myocardial infarctions (MIs) are frequently evident on routine chest or abdominal CT, even when studies are not performed for cardiac-specific indications. However, the telltale signs of an MI may be easily overlooked. Herein, we present the spectrum of appearances of MIs, including areas of fat attenuation, myocardial calcifications, focal areas of wall thinning or aneurysm formation, and perfusion abnormalities. Thrombi, especially when present at the apex of the left ventricle, may also suggest an MI. CONCLUSION: The increased use of CT in the evaluation of patients for a variety of indications gives the radiologist the unique opportunity to recognize findings consistent with MI in patients who may not have a prior diagnosis of ischemic heart disease.

Gestational weight change and childhood body composition trajectories from pregnancy to early adolescence.

OBJECTIVE: A mother-child dyad trajectory model of weight and body composition spanning from conception to adolescence was developed to understand how early life exposures shape childhood body composition. METHODS: African American (49.3%) and Dominican (50.7%) pregnant mothers (n = 337) were enrolled during pregnancy, and their children (47.5% female) were followed from ages 5 to 14. Gestational weight gain (GWG) was abstracted from medical records. Child weight, height, percentage body fat, and waist circumference were measured. GWG and child body composition trajectories were jointly modeled with a flexible latent class model with a class membership component that included prepregnancy BMI. RESULTS: Four prenatal and child body composition trajectory patterns were identified, and sex-specific patterns were observed for the joint GWG-postnatal body composition trajectories with more distinct patterns among girls but not boys. Girls of mothers with high GWG across gestation had the highest BMI z score, waist circumference, and percentage body fat trajectories from ages 5 to 14; however, boys in this high GWG group did not show similar growth patterns. CONCLUSIONS: Jointly modeled prenatal weight and child body composition trajectories showed sex-specific patterns. Growth patterns from childhood though early adolescence appeared to be more profoundly affected by higher GWG patterns in females, suggesting sex differences in developmental programming.

Handling Missing Data in Instrumental Variable Methods for Causal Inference.

It is very common in instrumental variable studies for there to be missing instrument data. For example, in the Wisconsin Longitudinal Study one can use genotype data as a Mendelian randomization-style instrument, but this information is often missing when subjects do not contribute saliva samples, or when the genotyping platform output is ambiguous. Here we review missing-at-random assumptions one can use to identify instrumental variable causal effects, and discuss various approaches for estimation and inference. We consider likelihood-based methods, regression and weighting estimators, and doubly robust estimators. The likelihood-based methods yield the most precise inference, and are optimal under the model assumptions, while the doubly robust estimators can attain the nonparametric efficiency bound while allowing flexible nonparametric estimation of nuisance functions (e.g., instrument propensity scores). The regression and weighting estimators can sometimes be easiest to describe and implement. Our main contribution is an extensive review of this wide array of estimators under varied missing-at-random assumptions, along with discussion of asymptotic properties and inferential tools. We also implement many of the estimators in an analysis of the Wisconsin Longitudinal Study, to study effects of impaired cognitive functioning on depression.

Imaging of the cisterna chyli on PET-CT in patients with known malignancy: Report of two cases.

A normal cisterna chyli is a structure that may simulate retrocrural adenopathy on unenhanced CT. Our case report is significant because it highlights two cases in which patients with prior primary malignancies (medullary thyroid carcinoma, esophageal carcinoma) underwent PET-CT for re-staging, and in each case, a prominent right retrocrural structure is seen representing either a cisterna chyli or retrocrural metastasis. The physiologic activity of the structure on PET-CT is considered and cross-sectional abdominal images are examined in full as well. In both cases, the structure has a low attenuation on CT and a low SUVmax on PET-CT, consistent with a benign process. These cases demonstrate that with the combined use of CT attenuation and PET SUVmax as guiding parameters, a cisterna chyli should be more readily distinguishable from retrocrural adenopathy, and thus can help to avoid unnecessary invasive management of the patient.

Calcific constrictive pericarditis demonstrated on 99mTc-MDP bone scintigraphy.

The authors present a case of calcific constrictive pericarditis, imaged with bone scintigraphy. The patient presented with three months of shortness of breath, chest pain, and chest tightness during exercise, among other nonspecific symptoms. Although the diagnosis was made based on chest radiography and cardiac MRI, bone scintigraphy was used to corroborate the diagnosis of calcific constrictive pericarditis. Bone scintigraphy showed a pattern of tracer accumulation consistent with pericardial uptake. Calcific constrictive pericarditis was also confirmed at the time of surgery.