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Diabetic pregnancies are cleary associated with maternal type 2 diabetes and metabolic syndrome as well as atherosclerotic diseases in the offspring. The global prevalence of hyperglycemia in pregnancy was estimated as 15.8% of live births to women in 2019, with an upward trend. Numerous parental risk factors as well as trans-generational mechanisms targeting the utero-placental system, leading to diabetes, dysmetabolic and atherosclerotic conditions in the next generation, seem to be involved within this pathophysiological context. To focus on the predictable impact of trans-generational diabetic programming, we studied age- and gender-matched offspring of diabetic and nondiabetic mothers. The offspring generation consists of three groups: C57BL/6-J-Ins2Akita (positive control group), wild-type C57BL/6-J-Ins2Akita (experimental group), and C57BL/6-J mice (negative control group). We undertook intraperitoneal glucose tolerance tests at 3 and 11 weeks of age. Moreover, this in vivo model was complemented by a corresponding in silico model. Although at 3 weeks of age, no significant effects could be observed, we could demonstrate at 11 weeks of age characteristic and significant differences in relation to maternal diabetic imprinting based on the in silico model-based predictors. These predictors allow the generation of a concise classification tree assigning maternal diabetic imprinting correctly in 91% of study cases. Our data show that hyperglycemic in utero milieu contributes to trans-generational diabetic programming leading to impaired glucose tolerance in the offspring of diabetic mothers early on. These observations can be clearly and early distinguished from genetically determined diabetes, for example, type 1 diabetes, in which basal glucose values are significantly raised.
The chapter starts by describing the appearance and interpretation of a regression tree, followed by a more detailed explanation of the recursive partitioning algorithm used in the construction of tree models. We describe how optimum tree complexity is chosen based on the results of a crossvalidation procedure, and how a tree model can be simplified via its pruning. The concepts of competing and surrogate predictors are touched upon, both enabling a more effective application of the fitted tree models. The methods described in this chapter are accompanied by a carefully-explained guide to the R code needed for their use, in this case employing the rpart package.
To determine the prevalence and predictors of hypocalcaemia in under-five children (1–59 months) hospitalised with severe acute malnutrition (SAM).
A cross-sectional study was designed to determine the prevalence of hypocalcaemia among children hospitalised with SAM. Serum Ca and 25-hydroxycholecalciferol (25-(OH)D) were estimated. Hypocalcaemia was defined as serum Ca (albumin-adjusted) <2·12 mmol/l. To identify the clinical predictors of hypocalcaemia, a logistic regression model was constructed taking hypocalcaemia as a dependent variable, and sociodemographic and clinical variables as independent variables.
A tertiary care hospital in Delhi, between November 2017 and April 2019.
One-hundred and fifty children (1–59 months) hospitalised with SAM were enrolled.
Hypocalcaemia was documented in thirty-nine (26 %) children hospitalised with SAM, the prevalence being comparable between children aged <6 months (11/41, 26·8 %) and those between 6 and 59 months (28/109, 25·7 %) (P = 0·887). Vitamin D deficiency (serum 25-(OH)D <30 nmol/l) and clinical rickets were observed in ninety-eight (65·3 %) and sixty-three (42 %) children, respectively. Hypocalcaemia occurred more frequently in severely malnourished children with clinical rickets (OR 6·6, 95 % CI 2·54, 17·15, P < 0·001), abdominal distension (OR 4·5, 95 % CI 1·39, 14·54, P = 0·012) and sepsis (OR 2·6, 95 % CI 1·00, 6·57, P = 0·050).
Rickets and hypocalcaemia are common in children with SAM. Routine supplementation of vitamin D should be considered for severely malnourished children. Ca may be empirically prescribed to severely malnourished children with clinical rickets, abdominal distension and/or sepsis.
Patients with obsessive-compulsive disorder (OCD) are at increased risk for suicide attempt (SA) compared to the general population. However, the significant risk factors for SA in this population remains unclear – whether these factors are associated with the disorder itself or related to extrinsic factors, such as comorbidities and sociodemographic variables. This study aimed to identify predictors of SA in OCD patients using a machine learning algorithm.
A total of 959 outpatients with OCD were included. An elastic net model was performed to recognize the predictors of SA among OCD patients, using clinical and sociodemographic variables.
The prevalence of SA in our sample was 10.8%. Relevant predictors of SA founded by the elastic net algorithm were the following: previous suicide planning, previous suicide thoughts, lifetime depressive episode, and intermittent explosive disorder. Our elastic net model had a good performance and found an area under the curve of 0.95.
This is the first study to evaluate risk factors for SA among OCD patients using machine learning algorithms. Our results demonstrate an accurate risk algorithm can be created using clinical and sociodemographic variables. All aspects of suicidal phenomena need to be carefully investigated by clinicians in every evaluation of OCD patients. Particular attention should be given to comorbidity with depressive symptoms.
Adults with CHD have reduced work participation rates compared to adults without CHD. We aimed to quantify employment rate among adult CHD patients in a population-based registry and to describe factors and barriers associated with work participation.
We retrospectively identified adults with employment information in the North Carolina Congenital Heart Defects Surveillance Network. Employment was defined as any paid work in a given year. Logistic regression was used to examine patients’ employment status during each year.
The registry included 1,208 adult CHD patients with a health care encounter between 2009 and 2013, of whom 1,078 had ≥1 year of data with known employment status. Overall, 401 patients (37%) were employed in their most recent registry year. On multivariable analysis, the odds of employment decreased with older age and were lower for Black as compared to White patients (odds ratio = 0.78; 95% confidence interval: 0.62, 0.98; p = 0.030), and single as compared to married patients (odds ratio = 0.50; 95% confidence interval: 0.39, 0.63; p < 0.001).
In a registry where employment status was routinely captured, only 37% of adult CHD patients aged 18–64 years were employed, with older patients, Black patients, and single patients being less likely to be employed. Further work is needed to consider how enhancing cardiology follow-up for adults with CHD can integrate support for employment.
This 17-year prospective study applied a social-developmental lens to the challenge of distinguishing predictors of adolescent-era substance use from predictors of longer term adult substance use problems. A diverse community sample of 168 individuals was repeatedly assessed from age 13 to age 30 using test, self-, parent-, and peer-report methods. As hypothesized, substance use within adolescence was linked to a range of likely transient social and developmental factors that are particularly salient during the adolescent era, including popularity with peers, peer substance use, parent–adolescent conflict, and broader patterns of deviant behavior. Substance abuse problems at ages 27–30 were best predicted, even after accounting for levels of substance use in adolescence, by adolescent-era markers of underlying deficits, including lack of social skills and poor self-concept. The factors that best predicted levels of adolescent-era substance use were not generally predictive of adult substance abuse problems in multivariate models (either with or without accounting for baseline levels of use). Results are interpreted as suggesting that recognizing the developmental nature of adolescent-era substance use may be crucial to distinguishing factors that predict socially driven and/or relatively transient use during adolescence from factors that predict long-term problems with substance abuse that extend well into adulthood.
This chapter shifts from the more inductive approach that guides preceding chapters to a deductive one, using survey data to test existing theories about the causes and consequences of electoral violence. In doing so, the chapter shifts the unit of analysis from the region and group-level to the individual. The chapter has two main parts. The first examines the predictors of electoral violence, focusing specifically on the role of divisive land appeals in increasing an individual’s likelihood of experiencing violence. The second part focuses on the effects of violence, asking how the experience of election violence shapes openness toward ethnic outgroups, trust in political leadership, and engagement across ethnic lines. Broadly, the chapter shows that the experience of election violence has an enduring effect on how an individual perceives and engages with her political and social world. The chapter also emphasizes that studying the effects of electoral violence helps unpack the potential endogeneity of violence, enabling scholars to better specify the mechanisms through which election violence increases or diminishes the prospects for democratic consolidation and durable peace.
Background: Chest tube thoracostomy is frequently performed in the emergency department (ED) for patients with traumatic thoracic injuries. However, this procedure is associated with a high complication rate. Aim Statement: The aim of this study was to describe and assess predictors of complications following chest tube thoracostomy. Measures & Design: A retrospective chart review was conducted in a level 1 trauma center. Patients aged ≥16 who required a chest tube for a traumatic injury between 2016 and 2019 were identified. Variables including demographic data, Charlson Comorbidity Index, mechanism of injury, Injury Severity Score (ISS), chest tube insertion and technique (i.e. position, dislodgement, obstruction, organ perforation), complications and interventions were collected using a standardized data collection form. A second reviewer assessed all ambiguous files. Descriptive statistics and adjusted odds ratios were calculated. Evaluation/Results: 179 patients were included in the study, of which 141 were male (79%). Mean age was 54 18 and median ISS was 17 (Q1-Q3: 9-27). 207 chest tube thoracostomies were performed for pneumothorax (81%) or a hemothorax (38%) mainly after a blunt injury (92%). 183 standard chest tube (88%) and 24 pigtail catheters (12%) were installed. Overall, emergency medicine physicians/residents performed 70% of these procedures and 54% were performed by residents. Sixty-one patients (34%) suffered a total of 73 complications: 45 were infectious (62%) and 28 were technique-related (38%). Pneumonia was the most frequent complication (19%) followed by reintroduced or replaced chest tube (12%). After adjusting for the ISS, there was no statistically significant association between the type of tube (OR 0.36 95% CI: 0.08-1.68), the medical specialty (OR 1.19 95% CI: 0.55-2.58) or the level of training (OR 1.29 95% CI: 0.63-2.64) of the clinician and the incidence of at least one complication. Discussion/Impact: Our results show that one out of three patients experienced at least one complication following a chest tube thoracostomy in the ED, which confirmed existing literature (5%- 38%). After adjustment, the type of tube used, the specialty and level of training of the health professional who performed the procedure was not associated with the incidence of at least one complication.
Introduction: Vaginal bleeding in early pregnancy is a common emergency department (ED) presentation, with many of these episodes resulting in poor obstetrical outcome. These outcomes have been extensively studied, but there have been few evaluations of what variables are associated predictors. This study aimed to identify predictors of less than optimal obstetrical outcomes for women who present to the ED with early pregnancy bleeding. Methods: A regional centre health records review included pregnant females who presented to the ED with vaginal bleeding at <20 weeks gestation. This study investigated differences in presenting features between groups with subsequent optimal outcomes (OO; defined as a full-term live birth >37 weeks) and less than optimal outcomes (LOO; defined as a miscarriage, stillbirth or pre-term live birth). Predictor variables included: maternal age, gestational age at presentation, number of return ED visits, socioeconomic status (SES), gravida-para-abortus status, Rh status, Hgb level and presence of cramping. Rates and results of point of care ultrasound (PoCUS) and ultrasound (US) by radiology were also considered. Results: Records for 422 patients from Jan 2017 to Nov 2018 were screened and 180 patients were included. Overall, 58.3% of study participants had a LOO. The only strong predictor of outcome was seeing an Intra-Uterine Pregnancy (IUP) with Fetal Heart Beat (FHB) on US; OO rate 74.3% (95% CI 59.8-88.7; p < 0.01). Cramping (with bleeding) trended towards a higher rate of LOO (62.7%, 95% CI 54.2-71.1; p = 0.07). SES was not a reliable predictor of LOO, with similar clinical outcome rates above and below the poverty line (57.5% [95% CI 46.7-68.3] vs 59% [95% CI 49.3-68.6] LOO). For anemic patients, the non-live birth rate was 100%, but the number with this variable was small (n = 5). Return visits (58.3%, 95% CI 42.2-74.4), previous abortion (58.8%, 95% CI 49.7-67.8), no living children (60.2%, 95% CI 50.7-69.6) and past pregnancy (55.9%, 95% CI 46.6-65.1) were not associated with higher rates of LOO. Conclusion: Identification of a live IUP, anemia, and cramping have potential as predictors of obstetrical outcome in early pregnancy bleeding. This information may provide better guidance for clinical practice and investigations in the emergency department and the predictive value of these variables support more appropriate counseling to this patient population.
The goal of this study is to assess prevalence and incidence of psychiatric sequelae in a sample of inpatient accident survivors. Such an attempt to assess psychiatric conditions that originate due to an accident seems to be important; this does not include psychiatric conditions already present prior to the accident.
208 accident victims were consecutively examined over a period of 12 months using DSM-IV diagnostic assessment, CAPS, and self-evaluating questionnaires as well as ISS for injury severity. A predictor model for psychiatric disorders was set up.
Incidence of newly developed Axis I disorders in our sample was 14.2% (6 months) and 12.3% (12 months). Incidence of PTSD was 5.9% (6 months) and 2.5% (12 months). Comorbidity was a general phenomenon. The psychiatric condition prior to the accident could be identified as a predictor for the development of Axis I disorders. The subjectively evaluated intensity of experienced threat to life and female gender were the main predictors for the development of PTSD.
Accidents can lead to different psychiatric disorders. PTSD as a single diagnosis is rare. Without taking into account pre-existing disorders, the incidence may be overestimated. Two predictor models for the development of PTSD and other mental disorders are presented.
In order to identify clinical and demographic variables that predict response to antidepressants and to analyse prediction of outcome as a function of definition of outcome we analysed pooled data of two independent, multicentre, double blind parallel group studies. Study I compared the efficacy of mianserin with that of fluoxetine in 65, and study II compared mianserin with fluvoxamine in 60 patients with depression. Improvement was defined as at least 20% decrease in MADRS by day 14. Patients were considered as responders if they had greater than 50% decrease and non-responders if they had ≤ 50% decrease from baseline in the MADRS at day 56. Complete remission was defined as MADRS score ≤ 6 at day 56. Patients' characteristics did not differ between mianserin and SSRI groups. Early improvement predicted response in 92% and complete remission in 55% of the patients improved at day 14. Multivariate forward stepwise logistic regression analysis showed that response to treatments at day 56 was significantly (P = 0.0003) associated with early improvement, age (responders had higher age than non-responders) and weight (responders weighted more than non-responders). Complete remission was only predicted by early improvement. Treatments could not be differentiated when data were analysed according to responder/nonresponder status or complete remission/no complete remission. However, when the same data were analysed by analysis of variance a significant treatment effect (P = 0.02, mianserin > SSRIs) and a quadratic type treatment by time interaction (P = 0.023) were found. The robustness of the analysis was further improved by inclusion of covariates (age, weight). Early clinical improvement seems to be the best predictor of 2 month response to antidepressants (mianserin, SSRIs). Younger age and lower weight may predict non-response. Quantitative analysis differentiates treatments better than analysis of responder status. As obtenation of complete remission is a realistic objective with current antidepressants, studies longer than 2 months are needed to assess effectiveness of these drugs in the obtenation of complete remission.
The aim of this study was to ascertain predictors of work insufficiency in patients with panic disorder (PD) with agoraphobia (AG).
Linear regression was used to identify predictors of work insufficiency in a sample of 72 consecutive outpatients with PD with AG. Intensity of work insufficiency was ascertained from modified National Institute of Mental Health Panic Questionnaire (NIMH PQ). That represented dependent variable. Independent variables were demographic data, duration of illness, presence of comorbid current major depression episode, presence of any personality disorder and scores on the Panic and Agoraphobia Scale (PAS) subscales: panic attacks, AG (avoidance behavior), anticipatory anxiety and worries about health.
Patients reported severe work insufficiency. The best predict variable for the work insufficiency in patients with PD with AG was high score on the PAS dimension of AG.
Patients generally reported severe effects of PD with AG on work efficacy and the results suggested that the impaired work efficacy was the most associated with avoidance behavior. These results recommend that the treatment of PD with AG patients should be related to decreasing avoidance behavior in order to establish adequate work performance in patients.
In a long-term follow-up of anorexia nervosa (AN) patients, somatic, psychological and social variables at clinical presentation should be investigated using a multilevel approach.
This study isolated predictors known from the literature over longer time periods and carried out a separate investigation of predictors in a sample of 81 AN patients of the Heidelberg–Mannheim study over a mean period of 12 years (range 9–19 years). Separate hierarchic regression analyses on the basis of the course of the Morgan–Russell categories were calculated for four individually recorded areas: anamnestic, psychological, somatic and social data sets.
Age at the onset of the disease, purging behavior, low serum albumin, high glutamic-oxalo acetic transaminase (GOT) psychopathology (ANSS) and social pathology had the highest predictive value qualities. In survival analysis overall assessment of all six main predictors at clinical presentation could differentiate all patients who recovered from those who remained ill (log-rank test P = 0.019).
A small number of variables were important for detecting a good or poor long-term course of AN. At onset of the disease, it seems necessary to evaluate these psychological, somatic and social predictors.
Depression after childbirth is a major problem affecting 10–22% of all mothers. In Italy, postnatal depression has not yet been systematically studied.
In this retrospective study we have sought to identify risk factors, assessed during pregnancy, and their importance for postnatal depression symptoms in a sample of 297 Italian women attending ante-natal classes organised by the local Consultorio Familiare Unit of the National Health Service, Italy. The Postpartum Depression Predictors Inventory – revised form (PDPI-Revised), was used to identify risk factors, 8–9 month of pregnancy. A double-test strategy using the Edinburgh Postnatal Depression Scale (EPDS) and 12-item General Health Questionnaire (GHQ12), was administered to screen women with a higher occurrence of symptoms of postnatal depression six–eight weeks after delivery. Women with high EPDS (<8) and high GHQ12 (<3) scores were compared with those who had scored below the EPDS and/or GHQ12 threshold scores.
We found that 13% of the women studied showed high postnatal depressive symptomatology, which is very similar to rates of prevalence of postnatal depression in the first year after the birth of the child reported in other Western World studies. Feeling anxious during pregnancy is a strong predictor of high symptoms of depression at 6–8 weeks after delivery. However, University education and friends' support appear to be important protective factors.
These findings could be useful both for Italian health professionals and for researchers interested in the transcultural aspects of postnatal depression.
One hundred and thirteen long-term mentally ill clients receiving case management were investigated with regard to psychosocial and clinical predictors of changes in subjective quality of life during an 18-month follow-up. Better psychosocial functioning and fewer psychiatric symptoms at baseline predicted a greater improvement in quality of life. A larger decrease in symptom severity and a greater improvement in the social network during the follow-up were identified as the most important predictors of a greater improvement in subjective quality of life. The results of the study suggest that an emphasis should be put on effective symptom management, a reduction of needs for care and social support in order to fulfill the aims of improving subjective quality of life in patients receiving case management.
As panic disorder (PD) has a chronic course, it is important to identify predictors that might be related to non-remission. The aim of this study is to verify whether history of trauma and defense style are predictors to pharmacological treatment response in PD patients.
The sample was composed by 47 PD patients according to DSM-IV who were treated with sertraline for 16 weeks. Evaluations were assessed by the C.G.I. (Clinical Global Impression), the Hamilton-Anxiety Scale, the Hamilton-Depression Scale, the Panic Inventory and the DSQ-40 (Defense Style Questionnaire) at baseline and after treatment.
Full remission was observed in 61.7% of the sample. The predictors significantly associated with non-remission were: severity of PD (p = 0.012), age of onset (p = 0.02) and immature defenses (p = 0.032). In addition, the history of trauma was associated with early onset of PD (p = 0.043).
Panic patients had as predictors of worse response to pharmacological treatment the early onset and the severity of PD symptoms as well as the use of immature defenses at baseline. This finding corroborates the relevance of the evaluation of factors that might affect the response so as to enable the development of appropriate treatment for each patient.
To identify the presence of factors associated with treatment outcome in patients under group cognitive-behavioral therapy (GCBT) for obsessive-compulsive disorder (OCD).
Subjects and methods
This study evaluated 181 patients with OCD that attended a 12-session weekly GCBT program. Response criteria were: ≥35% reduction in Y-BOCS scores and global improvement score of the Clinical Global Impression (CGI) ≤ 2 at post-treatment evaluation. Sociodemographic data, OCD characteristics, and treatment data were studied.
In the bivariate analysis, the following variables showed statistical significance (p < 0.20) to enter the regression model: being woman (p = 0.074), greater insight (p = 0.017) and better quality of life (QOL) in all domains before treatment (p = 0.053), overall severity of disease according to the CGI (p = 0.007), number of associated comorbidities (p = 0.063), social phobia (p = 0.044), and dysthymia (p = 0.072). In the final regression model, these variables were associated with response to GCBT: female gender (p = 0.021); WHOQOL-BREF psychological domain (p = 0.011); insight (p = 0.042); and global improvement score of the CGI severity-scale before therapy (p = 0.045).
Special attention should be paid to patients with poor insight, increasing the cognitive aspects of the therapy in an attempt to modify the rigidity and fixity of their beliefs. In addition, male patients should be more observed, since they showed lower chance of response to GCBT when compared to women. Patients with more severe global symptoms (CGI) are poorer responders to GCBT, which indicates that not only obsessive-compulsive symptoms (OCS) should be evaluated, since other symptoms, such as depression and anxiety, may affect the treatment; therefore, an attempt to reduce these symptoms, prior to the treatment of OCD, should be considered as an option in some cases.
Many factors influencing compliance in schizophrenia have been reported in the literature. Our aim was to assess predictors of noncompliance in male patients with first-episode schizophrenia, schizophreniform and schizoaffective disorder in a naturalistic setting.
Subjects and methods
Fifty-six male patients, discharged from hospital, were included in a 1-year follow-up study. Psychopathological symptoms were assessed with positive and negative syndrome scale at admission and discharge, while extrapyramidal side effects were recorded weekly during hospitalisation using the Simpson–Angus and Barnes akathisia scales. Socio-demographic and some other variables were also recorded.
Thirty patients (53.6%) dropped out of treatment in the first year and 21 of them relapsed. With the Cox survival analysis three predictors of noncompliance were found: diagnosis of schizophrenia versus the other two diagnoses, positive symptoms at admission, and lack of insight at discharge.
In spite of a specific methodology and selection of only first-episode male patients, the results are in accordance with the findings of other authors. This confirms the universality of noncompliance in psychotic patients.
First-episode patients have a high dropout rate. However, in compliant patients, the relapse rate was low, and therefore special attention and compliance-promoting interventions in first-episode patients are needed.
Treatment-resistant schizophrenia does not exist as a discrete entity, so separating patients who will fail to respond to traditional antipsychotics from those who will respond is impossible with 100% accuracy. However, several predictors of poor clinical outcome have emerged from recent research and knowledge of the processes that lead to poor outcome has become increasingly important with the advent of atypical antipsychotics that may be used in patients with treatment-resistant illness. Much of the variation in outcome can be understood in terms of differences in sample selection, outcome definition and stringency of the diagnostic criteria used. Failure to appreciate these mechanisms may lead to over- or underestimation of the proportion of patients with poor treatment response in clinical and research settings. The importance of factors that predict poor outcome should be judged in terms of their effect size and the degree to which alternative explanations for the association with outcome have been excluded. Although much current research is being focused on specific biological predictors, baseline demographic and illness-related factors, such as ethnic group, sex, social class, type of onset, age of onset and concurrent misuse of alcohol or drugs, have large effects on outcome. Although duration of untreated psychosis before first contact with services may independently predict poor outcome, confounding by variables that are associated with both pathways to care and clinical outcome has not been excluded.
We report clinical and social outcomes of schizophrenia in the longitudinal, population-based Northern Finland 1966 Birth Cohort, and describe associated demographic, developmental and illness-related factors.
Subjects and methods
Subjects with DSM-III-R schizophrenia (n = 59) were followed prospectively from mid-gestation up to age 35 years. Outcome measures included positive and negative symptoms, psychiatric hospitalisations, social and occupational functioning. Several definitions of good and poor outcome were explored, and developmental, socio-demographic and clinical predictors of outcomes were analysed.
Good clinical outcome varied from 10% to 59%, and good social outcome 15–46%, depending on definition. Poor clinical outcome varied 41–77% and poor social 37–54%. Lack of friends in childhood, father's high social class, lower school performance and earlier age of illness onset predicted poor outcomes.
The outcomes of schizophrenia in this study depended on definitions used but were relatively poor. The age of illness onset, father's social class, school performance and poor social contacts in childhood were only statistically significant predictors.
Definitions of outcome have a major effect on estimates for proportions of good and bad outcomes and on the predictors of outcomes. However, regardless of which definitions were used, the outcome of schizophrenia in this population-based sample was generally bleak.