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JAMA Network Open Jun 2024The overutilization of antibiotics in very preterm infants (VPIs) at low risk of early-onset sepsis (EOS) is associated with increased mortality and morbidities....
IMPORTANCE
The overutilization of antibiotics in very preterm infants (VPIs) at low risk of early-onset sepsis (EOS) is associated with increased mortality and morbidities. Nevertheless, the association of early antibiotic exposure with bronchopulmonary dysplasia (BPD) remains equivocal.
OBJECTIVE
To evaluate the association of varying durations and types of early antibiotic exposure with the incidence of BPD in VPIs at low risk of EOS.
DESIGN, SETTING, AND PARTICIPANTS
This national multicenter cohort study utilized data from the Chinese Neonatal Network (CHNN) which prospectively collected data from January 1, 2019, to December 31, 2021. VPIs less than 32 weeks' gestational age or with birth weight less than 1500 g at low risk of EOS, defined as those born via cesarean delivery, without labor or rupture of membranes, and no clinical evidence of chorioamnionitis, were included. Data analysis was conducted from October 2022 to December 2023.
EXPOSURE
Early antibiotic exposure was defined as the total number of calendar days antibiotics were administered within the first week of life, which were further categorized as no exposure, 1 to 4 days of exposure, and 5 to 7 days of exposure.
MAIN OUTCOMES AND MEASURES
The primary outcome was the composite of moderate to severe BPD or mortality at 36 weeks' post menstrual age (PMA). Logistic regression was employed to assess factors associated with BPD or mortality using 2 different models.
RESULTS
Of the 27 176 VPIs included in the CHNN during the study period (14 874 male [54.7%] and 12 302 female [45.3%]), 6510 (23.9%; 3373 male [51.8%] and 3137 female [48.2.%]) were categorized as low risk for EOS. Among them, 1324 (20.3%) had no antibiotic exposure, 1134 (17.4%) received 1 to 4 days of antibiotics treatment, and 4052 (62.2%) received 5 to 7 days of antibiotics treatment. Of the 5186 VPIs who received antibiotics, 4098 (79.0%) received broad-spectrum antibiotics, 888 (17.1%) received narrow-spectrum antibiotics, and 200 (3.9%) received antifungals or other antibiotics. Prolonged exposure (5-7 days) was associated with increased likelihood of moderate to severe BPD or death (adjusted odds ratio [aOR], 1.23; 95% CI, 1.01-1.50). The use of broad-spectrum antibiotics (1-7 days) was also associated with a higher risk of moderate to severe BPD or death (aOR, 1.27; 95% CI, 1.04-1.55).
CONCLUSIONS AND RELEVANCE
In this cohort study of VPIs at low risk for EOS, exposure to prolonged or broad-spectrum antibiotics was associated with increased risk of developing moderate to severe BPD or mortality. These findings suggest that VPIs exposed to prolonged or broad-spectrum antibiotics early in life should be monitored for adverse outcomes.
Topics: Humans; Bronchopulmonary Dysplasia; Anti-Bacterial Agents; Infant, Newborn; Female; Male; Infant, Premature; Sepsis; China; Cohort Studies; Risk Factors; Incidence; Gestational Age; Infant, Very Low Birth Weight
PubMed: 38935376
DOI: 10.1001/jamanetworkopen.2024.18831 -
JAMA Network Open Jun 2024The US has the highest maternal mortality rate among developed countries. The Centers for Disease Control and Prevention deems nearly all of these deaths preventable,... (Observational Study)
Observational Study
IMPORTANCE
The US has the highest maternal mortality rate among developed countries. The Centers for Disease Control and Prevention deems nearly all of these deaths preventable, especially those attributable to mental health conditions. Coordination between US health care and social service systems could help further characterize circumstances and risks associated with perinatal suicide mortality.
OBJECTIVE
To examine contextual and individual precipitating circumstances and risks associated with perinatal suicide.
DESIGN, SETTING, AND PARTICIPANTS
This cross-sectional observational study used a convergent mixed methods design to explore factors contributing to maternal suicides and deaths of undetermined intent (hereinafter, undetermined deaths) identified in National Violent Death Reporting System (NVDRS) data for January 1, 2003, to December 31, 2021. Analyses included decedents who were aged 10 to 50 years and pregnant or post partum at death (collectively, the perinatal group) and demographically matched female decedents who were not pregnant or recently pregnant (nonperinatal group) at death. Analyses were performed between December 2022 and December 2023.
EXPOSURES
Pregnancy status at death (perinatal or nonperinatal).
MAIN OUTCOMES AND MEASURES
The main outcomes included contributing circumstances associated with suicides and undetermined deaths cited in coroner, medical examiner, or law enforcement case narratives. The study examined quantitative differences between groups using a matched analysis and characterized key themes of salient suicide circumstances using qualitative content analysis.
RESULTS
This study included 1150 perinatal decedents identified in the NVDRS: 456 (39.6%) were pregnant at death, 203 (17.7%) were pregnant within 42 days of death, and 491 (42.7%) were pregnant within 43 to 365 days before death, yielding 694 postpartum decedents. The nonperinatal comparison group included 17 655 female decedents aged 10 to 50 years. The mean (SD) age was 29.1 (7.4) years for perinatal decedents and 35.8 (10.8) years for nonperinatal decedents. Compared with matched nonperinatal decedents, perinatal decedents had higher odds of the following identified contributing circumstances: intimate partner problems (IPPs) (odds ratio [OR], 1.45 [95% CI, 1.23-1.72]), recent argument (OR, 1.33 [95% CI, 1.09-1.61]), depressed mood (OR, 1.39 [95% CI, 1.19-1.63]), substance abuse or other abuse (OR, 1.21 [95% CI, 1.03-1.42]), physical health problems (OR, 1.37 [95% CI, 1.09-1.72]), and death of a family member or friend (OR, 1.47 [95% CI, 1.06-2.02]). The findings of the qualitative analysis emphasized the importance of mental health and identified 128 decedents (12.4%) with postpartum depression.
CONCLUSIONS AND RELEVANCE
This study provides insights into complex factors surrounding maternal suicide, and it highlights opportunities for further research to understand long-term consequences of perinatal mental health. These findings also underscore the need for targeted evidence-based interventions and effective policies targeting mental health, substance use, and IPPs to prevent maternal suicide and enhance maternal health outcomes.
Topics: Humans; Female; Pregnancy; Cross-Sectional Studies; Adult; Suicide; United States; Adolescent; Middle Aged; Young Adult; Child; Risk Factors; Maternal Mortality; Perinatal Mortality
PubMed: 38935375
DOI: 10.1001/jamanetworkopen.2024.18887 -
Frontiers in Aging Neuroscience 2024The association of cognitive function, its changes, and all-cause mortality has not reached a consensus, and the independence of the association between changes in...
BACKGROUND
The association of cognitive function, its changes, and all-cause mortality has not reached a consensus, and the independence of the association between changes in cognitive function and mortality remains unclear. The purpose of this study was to evaluate the longitudinal association between baseline cognitive function and cognitive changes over 1 year with subsequent all-cause mortality among the older adults aged 60 and above.
METHODS
A prospective cohort study utilizing the Community Older Adults Health Survey data. Initiated in 2018, the study annually assessed all individuals aged 60+ in Dalang Town, Dongguan City. Cognitive function was assessed using the Chinese version of the Mini-Mental State Examination (MMSE). A total of 6,042 older adults individuals were included, and multivariate Cox proportional hazard models were used to examine cognitive function's impact on mortality.
RESULTS
Participants' median age was 70 years, with 39% men. Over a median 3.08-year follow-up, 525 died. Mortality risk increased by 6% per MMSE score decrease (adjusted = 1.06, 95%: 1.05-1.08). Compared to those with normal cognitive function at baseline, participants with mild cognitive impairment and moderate to severe cognitive impairment had significantly higher mortality risks (adjusted = 1.40, 95%: 1.07-1.82; = 2.49, 95%: 1.91-3.24, respectively). The risk of death was 5% higher for each one-point per year decrease in cognitive function change rate ( = 1.05, 95%CI: 1.02-1.08). Compared with participants with stable cognitive function, those with rapid cognitive decline had a 79% increased risk of death (adjusted = 1.79, 95% : 1.11-2.87), with baseline cognitive function influencing this relationship significantly ( for interaction = 0.002).
CONCLUSION
Baseline cognitive impairment and rapid cognitive decline are associated with higher all-cause mortality risks in Chinese older adults. Baseline function influences the mortality impact of cognitive changes.
PubMed: 38934019
DOI: 10.3389/fnagi.2024.1419235 -
The Pan African Medical Journal 2024Placenta accreta is a rare but serious placental attachment abnormality. The aim of this study is to analyze the epidemiological, clinical, para-clinical and...
[Placenta accreta: a retrospective descriptive study of 46 patients treated in the Obstetrics and Gynaecology Department of the Farhat Hached University Hospital in Sousse, Tunisia].
Placenta accreta is a rare but serious placental attachment abnormality. The aim of this study is to analyze the epidemiological, clinical, para-clinical and evolutionary features of placenta accreta, to investigate the therapeutic management and to assess maternal and neonatal morbidity and mortality. We conducted a retrospective, descriptive study of patients with histologically confirmed placenta accreta in the obstetrics and gynaecology department of the Farhat Hached University Hospital in Sousse, over a 4-year period from 1 January 2015 to 31 December 2019. The epidemiological, clinical, paraclinical, therapeutic and evolutionary data were collected from patients´ medical records and operative reports. In our series, we identified 46 cases of placenta accreta. The average age of our patients was 35±4.61 years. Each of our patients had a scarred uterus. The average term of delivery was 34 weeks of amenorrhoea and the mode of delivery was caesarean section for all our patients. First-line hysterectomy was performed in 40 patients and conservative treatment in 6. Sixteen patients developed maternal complications. No maternal death was observed. Placenta accreta is a rare condition associated with significant maternal and foetal morbidity.
Topics: Humans; Female; Retrospective Studies; Tunisia; Placenta Accreta; Adult; Pregnancy; Hospitals, University; Hysterectomy; Cesarean Section; Young Adult; Infant, Newborn; Conservative Treatment
PubMed: 38933434
DOI: 10.11604/pamj.2024.47.147.38111 -
EClinicalMedicine Jul 2024Children in low and middle-income countries remain vulnerable following hospital-discharge. We estimated the incidence and correlates of hospital readmission among young...
BACKGROUND
Children in low and middle-income countries remain vulnerable following hospital-discharge. We estimated the incidence and correlates of hospital readmission among young children admitted to nine hospitals in sub-Saharan Africa and South Asia.
METHODS
This was a secondary analysis of the CHAIN Network prospective cohort enrolled between 20th November 2016 and 31st January 2019. Children aged 2-23 months were eligible for enrolment, if admitted for an acute illness to one of the study hospitals. Exclusions were requiring immediate resuscitation, inability to tolerate oral feeds in their normal state of health, had suspected terminal illness, suspected chromosomal abnormality, trauma, admission for surgery, or their parent/caregiver was unwilling to participate and attend follow-up visits. Data from children discharged alive from the index admission were analysed for hospital readmission within 180-days from discharge. We examined ratios of readmission to post-discharge mortality rates. Using models with death as the competing event, we evaluated demographic, nutritional, clinical, and socioeconomic associations with readmission.
FINDINGS
Of 2874 children (1239 (43%) girls, median (IQR) age 10.8 (6.8-15.6) months), 655 readmission episodes occurred among 506 (18%) children (198 (39%) girls): 391 (14%) with one, and 115 (4%) with multiple readmissions, with a rate of: 41.0 (95% CI 38.0-44.3) readmissions/1000 child-months. Median time to readmission was 42 (IQR 15-93) days. 460/655 (70%) and 195/655 (30%) readmissions occurred at index study hospital and non-study hospitals respectively. One-third (N = 213/655, 33%) of readmissions occurred within 30 days of index discharge. Sites with fewest readmissions had the highest post-discharge mortality. Most readmissions to study hospitals (371/450, 81%) were for the same illness as the index admission. Age, prior hospitalisation, chronic conditions, illness severity, and maternal mental health score, but not sex, nutritional status, or physical access to healthcare, were associated with readmission.
INTERPRETATION
Readmissions may be appropriate and necessary to reduce post-discharge mortality in high mortality settings. Social and financial support, training on recognition of serious illness for caregivers, and improving discharge procedures, continuity of care and facilitation of readmission need to be tested in intervention studies. We propose the ratio of readmission to post-discharge mortality rates as a marker of overall post-discharge access and care.
FUNDING
The Bill & Melinda Gates Foundation (OPP1131320).
PubMed: 38933099
DOI: 10.1016/j.eclinm.2024.102676 -
Journal of Clinical Medicine Jun 2024: While the overall rate of infant mortality in the United States has been decreasing over decades, the racial disparity, defined as the difference between races, has...
: While the overall rate of infant mortality in the United States has been decreasing over decades, the racial disparity, defined as the difference between races, has increased. Even though a person's race cannot change, it may be possible to identify factors that mediate or cause this racial disparity. Evaluating the factors that mediate or cause racial disparity is imperative because current clinical recommendations could be based on preventative modalities that are more effective for white women and their children. : A Bayesian approach modeled the data from the full United States National Natality Database for the years 2016 to 2018. The binomial rate parameters for each combination of race and mediators provided the potential outcomes. Estimating the mediation outcomes, including total effect, controlled direct effect, mediated effect, and proportion mediated used common counterfactual definitions for these probabilities. : Maternal smoking, low birthweight, and teenage maternity interacted in causing racial disparity for infant mortality. The proportion of racial disparity attributable to low birthweight was approximately 0.73, with only small variations attributable to maternal smoking and teenage maternity. : The novel approach facilitated modeling of multiple mediators. Low birthweight caused racial disparity for infant mortality. The model can be extended to evaluate additional mediational factors with the objective of identifying the preventable causes.
PubMed: 38929992
DOI: 10.3390/jcm13123464 -
Journal of Clinical Medicine Jun 2024Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that predominantly affects women of childbearing age. Pregnancy in SLE patients poses unique... (Review)
Review
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that predominantly affects women of childbearing age. Pregnancy in SLE patients poses unique challenges due to the potential impact on maternal and fetal outcomes. We provide an overview of the management of SLE during pregnancy, including preconception risk stratification and counseling, treatment, and disease activity monitoring. These assessments are critical to minimize maternal and fetal adverse events in pregnant patients with SLE. Disease flares, preeclampsia, antiphospholipid syndrome complications, and maternal mortality are the major risks for a woman with SLE during gestation. Timely treatment of SLE relapse, differentiation of preeclampsia from lupus nephritis, and tailored management for antiphospholipid syndrome are essential for a successful pregnancy. Fetal outcomes include neonatal lupus (NL), preterm birth, cesarean delivery, fetal growth restriction (FGR), and small-for-gestational-age (SGA) infants. We focused on NL, linked to maternal anti-Ro/SS-A and anti-La/SS-B antibodies, which can lead to various manifestations, particularly cardiac abnormalities, in newborns. While there is a common consensus regarding the preventive effect of hydroxychloroquine, the role of echocardiographic monitoring and fluorinated steroid treatment is still debated. Finally, close postpartum monitoring and counseling for subsequent pregnancies are crucial aspects of care.
PubMed: 38929983
DOI: 10.3390/jcm13123454 -
Journal of Personalized Medicine May 2024The term dystocia refers to labor characterized by a slow progression with delayed rates or even pauses in the dilation of the cervix or the descent of the fetus.... (Review)
Review
The term dystocia refers to labor characterized by a slow progression with delayed rates or even pauses in the dilation of the cervix or the descent of the fetus. Dystocia describes the deviation from the limits that define a normal birth and is often used as a synonym for the term pathological birth. Shoulder dystocia, also known as the manual exit of the shoulders during vaginal delivery on cephalic presentation, is defined as the "failure of the shoulders to spontaneously traverse the pelvis after delivery of the fetal head". This means that obstetric interventions are necessary to deliver the fetus's body after the head has been delivered, as gentle traction has failed. Abnormal labor (dystocia) is expressed and represented in partograms or by the prolongation of the latent phase or by slowing and pausing in the phases of cervical dilatation and fetal descent. While partograms are helpful in visualizing the progress of labor, regular use of them has not been shown to enhance obstetric outcomes considerably, and no partogram has been shown to be superior to others in comparative trials. Dystocia can, therefore, appear in any phase of the evolution of childbirth, so it is necessary to simultaneously assess all the factors that may contribute to its abnormal evolution, that is, the forces exerted, the weight, the shape, the presentation and position of the fetus, the integrity and morphology of the pelvis, and its relation to the fetus. When this complication occurs, it can result in an increased incidence of maternal morbidity, as well as an increased incidence of neonatal morbidity and mortality. Although several risk factors are associated with shoulder dystocia, it has proven impossible to recognize individual cases of shoulder dystocia in practice before they occur during labor. Various guidelines have been published for the management of shoulder dystocia, with the primary goal of educating the obstetrician and midwife on the importance of a preplanned sequence of maneuvers, thereby reducing maternal and neonatal morbidity and mortality.
PubMed: 38929807
DOI: 10.3390/jpm14060586 -
Children (Basel, Switzerland) Jun 2024The objective of this study was to assess the relationship of ACS with neonatal outcomes among very preterm infants born to mothers with clinical chorioamnionitis in...
The objective of this study was to assess the relationship of ACS with neonatal outcomes among very preterm infants born to mothers with clinical chorioamnionitis in China. This was a multicenter retrospective cohort study. Study participants included infants born at <32 weeks' gestation with clinical chorioamnionitis and registered in the Chinese Neonatal Network from 1 January 2019 to 31 December 2020. Infants were divided into two groups: any amount of ACS or no administration of ACS. Multivariable generalized linear models using generalized estimating equations were used to assess the association between ACS and neonatal outcomes among the study population. We identified 2193 infants eligible for this study; 1966 (89.6%) infants had received ACS therapy, and 227 (10.4%) had not received any ACS therapy. Among very preterm infants born to mothers with clinical chorioamnionitis, any ACS usage was significantly associated with decreased risks of early death (aRR 0.56, 95% CI 0.32, 0.99) and severe ROP (aRR 0.51, 95% CI 0.28, 0.93) after adjustment for maternal hypertension, gestational age at birth, Caesarean section, being inborn, and administration of systemic antibiotics to the mother within 24 h before birth. In addition, out of the 2193 infants, the placentas of 1931 infants underwent pathological examination with recorded results. Subsequently, 1490 of these cases (77.2%) were diagnosed with histological chorioamnionitis. In 1490 cases of histologic chorioamnionitis, any ACS usage was significantly related to decreased risks of overall mortality (aRR 0.52, 95% CI 0.31, 0.87), severe ROP (aRR 0.47, 95% CI 0.25, 0.97), and respiratory distress syndrome (aRR 0.52, 95% CI 0.31, 0.87). We concluded that any ACS was associated with reduced risks for neonatal early death and severe ROP among very preterm infants born to mothers with clinical chorioamnionitis.
PubMed: 38929259
DOI: 10.3390/children11060680 -
International Journal of Molecular... Jun 2024The placenta is a crucial determinant of fetal survival, growth, and development. Deficiency in placental development directly causes intrauterine growth retardation...
The placenta is a crucial determinant of fetal survival, growth, and development. Deficiency in placental development directly causes intrauterine growth retardation (IUGR). IUGR can lead to fetal growth restriction and an increase in the mortality rate. The genetic mechanisms underlying IUGR development, however, remain unclear. In the present study, we integrated whole-genome DNA methylation and transcriptomic analyses to determine distinct gene expression patterns in various placental tissues to identify pivotal genes that are implicated with IUGR development. By performing RNA-sequencing analysis, 1487 differentially expressed genes (DEGs), with 737 upregulated and 750 downregulated genes, were identified in IUGR pigs (H_IUGR) compared with that in normal birth weight pigs (N_IUGR) ( < 0.05); furthermore, 77 miRNAs, 1331 lncRNAs, and 61 circRNAs were differentially expressed. The protein-protein interaction network analysis revealed that among these DEGs, the genes GNGT1, ANXA1, and CDC20 related to cellular developmental processes and blood vessel development were the key genes associated with the development of IUGR. A total of 495,870 differentially methylated regions were identified between the N_IUGR and H_IUGR groups, which included 25,053 differentially methylated genes (DMEs); moreover, the overall methylation level was higher in the H_IUGR group than in the N_IUGR group. Combined analysis showed an inverse correlation between methylation levels and gene expression. A total of 1375 genes involved in developmental processes, tissue development, and immune system regulation exhibited methylation differences in gene expression levels in the promoter regions and gene ontology regions. Five genes, namely, ANXA1, ADM, NRP2, SHH, and SMAD1, with high methylation levels were identified as potential contributors to IUGR development. These findings provide valuable insights that DNA methylation plays a crucial role in the epigenetic regulation of gene expression and mammalian development and that DNA-hypermethylated genes contribute to IUGR development in Rongchang pigs.
Topics: Animals; Fetal Growth Retardation; DNA Methylation; Swine; Female; Pregnancy; Placenta; Gene Expression Profiling; Protein Interaction Maps; Epigenesis, Genetic; MicroRNAs; Transcriptome; Gene Regulatory Networks
PubMed: 38928167
DOI: 10.3390/ijms25126462