Psychobehavioral Responses, Post-Traumatic Stress and Depression in Pregnancy During the Early Phase of COVID-19 Outbreak

Objective

The novel coronavirus disease (COVID-19) outbreak has aroused a range of negative effects. Such considerable influence can be greater in vulnerable populations including pregnant women. This study aimed to assess the presence of prenatal depression (PND, as an important risk factor of postpartum depression) and post-traumatic stress disorder (PTSD) and to characterize infection-induced preventive behaviors and psychological responses in the early phase of COVID-19 outbreak.

Methods

Based on a population-based sample of pregnant women from all regions in China, presence of probable PND and suspected PTSD were assessed using the Edinburgh Postnatal Depression Scale (≥13) and the PTSD Checklist (≥14), respectively. A web-based questionnaire was used to assess psychological and behavioral responses to COVID-19.

Results

Among a total of 1908 questionnaires returned, 1901 women provided valid data (mean [SD] age, 28.9 [4.7] years). High prevalence of probable PND (34%) and suspected PTSD (40%) among pregnant women was observed. Those with suspected PTSD presented six times higher risk of probable PND than the non-suspected (OR=7.83, 95% CI: 6.29-9.75; p<0.001). Most women (91%-96%) reported anxiousness about infection of themselves and the members within their social network. Lack of security and loss of freedom were reported in approximately two-thirds of pregnant women. More frequent preventive behaviors, including handwashing, use of facemasks, and staying at home, were undertaken in more than 80% of the sample. Anxiousness of miscarriage and preterm birth were prevalent (>75%).

Conclusions

High prevalence of PND and PTSD and high levels of anxiety suggest profound impacts of the present outbreak on mental health. This calls for special attention and support for vulnerable populations. Mental health care should become part of public health measures during the present outbreak and should continue to be intensified to empower the health system for post-outbreak periods.

Abstract PR-010: Blinded and meta-analysis validation of an improved serological test for PDAC using the combination of CA19-9 and the sTRA glycan

Improvements in the clinical outcomes of pancreatic cancer patients may be achieved if physicians could identify the disease earlier. Recent studies demonstrated the promise of a biomarker panel is a simple combination between CA19-9 and another marker called sTRA, so named because it detects the sialylated version of the glycan bound by the TRA-1-60 (tumor-related antigen) antibody. The sTRA glycan is structurally related to the CA19-9 antigen and is produced by a different subtype of cancer cells than make CA19-9. We hypothesized that, among patients with PDAC, different patients have plasma elevations in CA19-9 than have plasma elevations in sTRA, and that as a result, a panel comprising the two markers detects more cancers at high specificity (low false-positive rate) than either marker alone. To test this hypothesis, we analyzed the relationships and biomarker performance of CA19-9 and sTRA across seven different datasets, encompassing 729 patient samples collected from four different clinical centers. We tested whether unique elevation occurred for each marker in each dataset, and whether the combination of markers performed better than then individual markers for distinguishing PDAC from healthy subjects and from benign pancreatic disease. We observed complementary elevations of sTRA or CA19-9 in the PDAC patients in each dataset. A two-marker panel composed of CA19-9 and sTRA and a three-marker panel composed of CA19-9 and two versions of the sTRA immunoassay gave statistically significant improvements over CA19-9 across the datasets for distinguishing PDAC from non-PDAC samples (healthy, chronic pancreatitis, pancreatic cyst, and biliary stricture/stones). At 95% specificity, sensitivity was improved from 36-55% across datasets for CA19-9 to 61-67% across datasets for the three-marker panel. The lead panel further showed 95% specificity and 61% sensitivity using blinded calls on another validation set (N = 340). This analysis serves as broad support for an improved serological test for PDAC using the combination of CA19-9 and sTRA. In light of this level of validation, the lead panel could be considered the most promising panel from the currently available information. If further validated using clinical assays, it may be good enough for surveillance among patients with increased risk for PDAC, in combination with follow-up modalities to establish diagnosis.

Citation Format: Ying Liu, Ben Staal, Daniel Barnett, Zonglin He, Chongfeng Gao, Mark Hurd, Pamela Bartlett, Aatur Singhi, J. Bradley Morrow, Gregory Cote, Anirban Maitra, Ying Huang, Randall Brand, Brian Haab. Blinded and meta-analysis validation of an improved serological test for PDAC using the combination of CA19-9 and the sTRA glycan [abstract]. In: Proceedings of the AACR Virtual Special Conference on Pancreatic Cancer; 2020 Sep 29-30. Philadelphia (PA): AACR; Cancer Res 2020;80(22 Suppl):Abstract nr PR-010.

The association between secondhand smoke and childhood asthma: A systematic review and meta-analysis

BACKGROUND

Secondhand smoke (SHS) exposure can trigger asthma exacerbations in children. Different studies have linked increased asthma symptoms and even deaths in children with SHS, but the risk has not been quantified uniformly across studies. We aimed to investigate the role of SHS exposure as a risk factor of asthma among children.

METHODS

We performed a systematic review in PubMed, Scopus, and Google Scholar from June 1975 to 10 March 2020. We included cohort, case-control, and cross-sectional studies reporting odds ratio (OR) or relative risk estimates and confidence intervals of all types of SHS exposure and childhood asthma.

RESULTS

Of the 26 970 studies identified, we included 93 eligible studies (42 cross-sectional, 41 cohort, and 10 case-control) in the meta-analysis. There were significantly positive associations between SHS exposure and doctor-diagnosed asthma (OR = 1.24; 95% confidence interval (CI) = 1.20-1.28), wheezing (OR = 1.27; 95% CI = 1.23-1.32) and asthma-like syndrome (OR = 1.34; 95% CI = 1.34-1.64). The funnel plots of all three outcomes skewed to the right, indicating that the studies generally favor a positive association of the disease with tobacco exposure. Subgroup analysis demonstrated that younger children tended to suffer more from developing doctor-diagnosed asthma, but older children (adolescents) suffered more from wheezing. There was no evidence of significant publication or small study bias using Egger's and Begg's tests.

CONCLUSION

The results show a positive association between prenatal and postnatal secondhand smoking exposure and the occurrence of childhood asthma, asthma-like syndrome, and wheezing. These results lend support to continued efforts to reduce childhood exposure to secondhand smoke.

A New Era of Epidemiology: Digital Epidemiology for Investigating the COVID-19 Outbreak in China

A novel pneumonia-like coronavirus disease (COVID-19) caused by a novel coronavirus named SARS-CoV-2 has swept across China and the world. Public health measures that were effective in previous infection outbreaks (eg, wearing a face mask, quarantining) were implemented in this outbreak. Available multidimensional social network data that take advantage of the recent rapid development of information and communication technologies allow for an exploration of disease spread and control via a modernized epidemiological approach. By using spatiotemporal data and real-time information, we can provide more accurate estimates of disease spread patterns related to human activities and enable more efficient responses to the outbreak. Two real cases during the COVID-19 outbreak demonstrated the application of emerging technologies and digital data in monitoring human movements related to disease spread. Although the ethical issues related to using digital epidemiology are still under debate, the cases reported in this article may enable the identification of more effective public health measures, as well as future applications of such digitally directed epidemiological approaches in controlling infectious disease outbreaks, which offer an alternative and modern outlook on addressing the long-standing challenges in population health.

An Innovative Artificial Intelligence-Based App for the Diagnosis of Gestational Diabetes Mellitus (GDM-AI): Development Study

Background

Gestational diabetes mellitus (GDM) can cause adverse consequences to both mothers and their newborns. However, pregnant women living in low- and middle-income areas or countries often fail to receive early clinical interventions at local medical facilities due to restricted availability of GDM diagnosis. The outstanding performance of artificial intelligence (AI) in disease diagnosis in previous studies demonstrates its promising applications in GDM diagnosis.

Objective

This study aims to investigate the implementation of a well-performing AI algorithm in GDM diagnosis in a setting, which requires fewer medical equipment and staff and to establish an app based on the AI algorithm. This study also explores possible progress if our app is widely used.

Methods

An AI model that included 9 algorithms was trained on 12,304 pregnant outpatients with their consent who received a test for GDM in the obstetrics and gynecology department of the First Affiliated Hospital of Jinan University, a local hospital in South China, between November 2010 and October 2017. GDM was diagnosed according to American Diabetes Association (ADA) 2011 diagnostic criteria. Age and fasting blood glucose were chosen as critical parameters. For validation, we performed k-fold cross-validation (k=5) for the internal dataset and an external validation dataset that included 1655 cases from the Prince of Wales Hospital, the affiliated teaching hospital of the Chinese University of Hong Kong, a non-local hospital. Accuracy, sensitivity, and other criteria were calculated for each algorithm.

Results

The areas under the receiver operating characteristic curve (AUROC) of external validation dataset for support vector machine (SVM), random forest, AdaBoost, k-nearest neighbors (kNN), naive Bayes (NB), decision tree, logistic regression (LR), eXtreme gradient boosting (XGBoost), and gradient boosting decision tree (GBDT) were 0.780, 0.657, 0.736, 0.669, 0.774, 0.614, 0.769, 0.742, and 0.757, respectively. SVM also retained high performance in other criteria. The specificity for SVM retained 100% in the external validation set with an accuracy of 88.7%.

Conclusions

Our prospective and multicenter study is the first clinical study that supports the GDM diagnosis for pregnant women in resource-limited areas, using only fasting blood glucose value, patients’ age, and a smartphone connected to the internet. Our study proved that SVM can achieve accurate diagnosis with less operation cost and higher efficacy. Our study (referred to as GDM-AI study, ie, the study of AI-based diagnosis of GDM) also shows our app has a promising future in improving the quality of maternal health for pregnant women, precision medicine, and long-distance medical care. We recommend future work should expand the dataset scope and replicate the process to validate the performance of the AI algorithms.

The economic burden of medical treatment of children with asthma in China

Background

At present, there are few studies on the economic burden and medical treatment of children with asthma in China. Thus this study aimed to investigate the economic burden of medical treatment of children with asthma in China.

Method

The 2015 China Medical Insurance Research Association (CHIRA) database was searched for patients with asthma from 0 to 14 years old. A cross-sectional study with cost analysis was conducted.

Results

The annual per capita direct medical cost was RMB 525 (US$75) related to asthma. Totaling 58% of the medical expenditure for asthma was covered by insurance in China, the majority of which were direct medical costs. Those that have the highest rates of using antibiotics were central China (100.0%), children aged 3 years and under (63.6%), as well as fourth-tier and fifth-tier cities (77.1%). Outpatient clinics (98.58% vs 1.42%, P < 0.01), tertiary hospitals (62.08% vs 37.92%, P < 0.01), and general hospitals (72.27% vs 27.73%, P < 0.01) were more often visited than the inpatient clinics, secondary and primary as well as the specialized clinics, respectively.

Conclusion

The economic burden of childhood asthma in China is relatively low, and the national medical insurance reduces their economic burden to a large extent. Abuse of antibiotics in treating asthma was found in China. There remain opportunities to strengthen the hierarchical medical system, reducing hospitalization and emergency visits, and ultimately reducing the economic burden of children with asthma.

Economic burden of IADPSG gestational diabetes diagnostic criteria in China: propensity score matching analysis from a 7-year retrospective cohort

INTRODUCTION

The International Association of Diabetes and Pregnancy Study Group (IADPSG) criteria for gestational diabetes mellitus (GDM) increased the morbidity significantly, but the cost and effectiveness of its application are still unclear. This study aimed to analyze the impact of the IADPSG criteria for diagnosing GDM in China on the perinatal outcomes, and medical expenditure of GDM women versus those with normal glucose tolerance (NGT).

RESEARCH DESIGN AND METHODS

We conducted a retrospective cohort study involving 7794 women admitted at the First Affiliated Hospital of Jinan University (Guangzhou, China), from November 1, 2010 to October 31, 2017. The perinatal outcomes and medical expenditure were retrieved from the electronic medical records in the hospital. Propensity score matching (PSM, in a 1:1 ratio) algorithm was used to minimize confounding effects on the difference in the two cohorts.

RESULTS

PSM minimized the difference of baseline characteristics between women with and without GDM. Of 7794 pregnant women, half (n=3897) were all of the pregnant women with GDM admitted to the hospital during the period, the other half women had NGT and were selected randomly to match with their counterparts. Adopting the IADPSG criteria was associated with reduced risk of emergency cesarean section, polyhydramnios, turbid amniotic fluid and perineal injury (p<0.01 for all) and having any one of the adverse fetal outcomes (p<0.01), including fetal distress, umbilical cord around the neck, neonatal encephalopathy, admission to neonatal intensive care unit, birth trauma, neonatal hypoglycemia and fetal death. After PSM, the median total medical expenditure by the GDM women was ¥912.9 (US$140.7 in 2015) more than that of the the NGT women (p=0.09).

CONCLUSIONS

Despite the increasing medical expenditure, screening at 24-28 gestational weeks under the IADPSG guidelines with the 2-hour, 75 g oral glucose tolerance test can improve short-term maternal and neonatal outcomes.

Gut T cell-independent IgA responses to commensal bacteria require engagement of the TACI receptor on B cells

The gut mounts secretory immunoglobulin A (SIgA) responses to commensal bacteria through nonredundant T cell-dependent (TD) and T cell-independent (TI) pathways that promote the establishment of mutualistic host-microbiota interactions. SIgAs from the TD pathway target penetrant bacteria, and their induction requires engagement of CD40 on B cells by CD40 ligand on T follicular helper cells. In contrast, SIgAs from the TI pathway bind a larger spectrum of bacteria, but the mechanism underpinning their production remains elusive. Here, we show that the intestinal TI pathway required CD40-independent B cell-activating signals from TACI, a receptor for the innate CD40 ligand-like factors BAFF and APRIL. TACI-induced SIgA responses targeted a fraction of the gut microbiota without shaping its overall composition. Of note, TACI was dispensable for TD induction of IgA in gut-associated lymphoid organs. Thus, BAFF/APRIL signals acting on TACI orchestrate commensal bacteria-specific SIgA responses through an intestinal TI program.

Phosphorylation of 5-LOX: The Potential Set-point of Inflammation

Inflammation secondary to tissue injuries serves as a double-edged sword that determines the prognosis of tissue repair. As one of the most important enzymes controlling the inflammation process by producing leukotrienes, 5-lipoxygenase (5-LOX, also called 5-LO) has been one of the therapeutic targets in regulating inflammation for a long time. Although a large number of 5-LOX inhibitors have been explored, only a few of them can be applied clinically. Surprisingly, phosphorylation of 5-LOX reveals great significance in regulating the subcellular localization of 5-LOX, which has proven to be an important mechanism underlying the enzymatic activities of 5-LOX. There are at least three phosphorylation sites in 5-LOX jointly to determine the final inflammatory outcomes, and adjustment of phosphorylation of 5-LOX at different phosphorylation sites brings hope to provide an unrecognized means to regulate inflammation. The present review intends to shed more lights into the set-point-like mechanisms of phosphorylation of 5-LOX and its possible clinical application by summarizing the biological properties of 5-LOX, the relationship of 5-LOX with neurodegenerative diseases and brain injuries, the phosphorylation of 5-LOX at different sites, the regulatory effects and mechanisms of phosphorylated 5-LOX upon inflammation, as well as the potential anti-inflammatory application through balancing the phosphorylation-depended set-point.

[Novel insight into the role of gut microbiome in colorectal surgery]

Colorectal surgery is a major therapeutic approach for various colorectal diseases. Surgery and perioperative management, such as fasting, mechanical bowel preparation, and antibiotics use, have an impact on the composition and function of gut microbiome. Abnormal microbiome reconstruction may lead to multiple complications, including infection, gastrointestinal dysfunction, anastomotic leak and disease recurrence. The aim of this review is to elucidate the roles and mechanisms of perioperative interventions of colorectal surgery on gut microbiome, which may provide a novel insight into the microbe-based therapies in the perioperative period of colorectal surgery.

Chromosomal abnormalities detected by karyotyping and microarray analysis in twins with structural anomalies

OBJECTIVES

To evaluate the incidence and types of chromosomal abnormalities detected in twins with structural anomalies and compare their distribution according to chorionicity and amnionicity and by structural-anomaly type. The added value of chromosomal microarray analysis (CMA) over conventional karyotyping in twins was also estimated.

METHODS

This was a single-center, retrospective analysis of 534 twin pregnancies seen over an 11-year period, in which one or both fetuses were diagnosed with congenital structural anomalies on ultrasound. The ultrasound findings and invasive prenatal diagnostic results were reviewed. Twin pregnancies were categorized as monochorionic monoamniotic (MCMA), monochorionic diamniotic (MCDA) or dichorionic diamniotic (DCDA). Chromosomal abnormalities detected by G-banding karyotyping and/or CMA were analyzed by chorionicity and amnionicity and by structural-anomaly type.

RESULTS

The 534 twin pairs analyzed comprised 25 pairs of MCMA, 112 pairs of MCDA and 397 pairs of DCDA twins. Of the 549 fetuses affected by structural anomalies, 432 (78.7%) underwent invasive prenatal testing and cytogenetic results were obtained. The incidence of overall chromosomal abnormalities in the DCDA fetuses (25.4%) was higher than that in the MCMA (3.7%) and MCDA (15.3%) fetuses. The incidence of aneuploidy was significantly higher in the DCDA group (22.8%) than in the MCMA (0.0%) and MCDA (12.4%) groups. The incidence of chromosomal abnormalities detected in fetuses, with anomalies of the cardiovascular, faciocervical, musculoskeletal, genitourinary and gastrointestinal systems, was higher in the DCDA group than in the MCDA group. In both the DCDA and MCDA groups, hydrops fetalis was associated with the highest incidence of chromosomal abnormality; of these fetuses, 67.6% had Turner syndrome (45,X). Pathogenic copy-number variations (CNVs) undetectable by karyotyping were identified by CMA in five (2.0%; 95% CI, 0.3-3.7%) DCDA fetuses. No pathogenic CNVs were found in MCMA and MCDA twins.

CONCLUSIONS

Dichorionic twins with structural anomalies have a higher risk of chromosomal abnormalities, especially aneuploidies, than do monochorionic twins. The incremental diagnostic yield of CMA over karyotyping seems to be lower (2.0%) in twins than that reported in singleton pregnancy. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Facemask shortage and the novel coronavirus disease (COVID-19) outbreak: Reflections on public health measures

BACKGROUND

A novel coronavirus disease (COVID-19) outbreak due to the severe respiratory syndrome coronavirus (SARS-CoV-2) infection occurred in China in late December 2019. Facemask wearing with proper hand hygiene is considered an effective measure to prevent SARS-CoV-2 transmission, but facemask wearing has become a social concern due to the global facemask shortage. China is the major facemask producer in the world, contributing to 50% of global production. However, a universal facemask wearing policy would put an enormous burden on the facemask supply.

METHODS

We performed a policy review concerning facemasks using government websites and mathematical modelling shortage analyses based on data obtained from the National Health Commission (NHC), the Ministry of Industry and Information Technology (MIIT), the Centre for Disease Control and Prevention (CDC), and General Administration of Customs (GAC) of the People's Republic of China. Three scenarios with respect to wearing facemasks were considered: (1) a universal facemask wearing policy implementation in all regions of mainland China; (2) a universal facemask wearing policy implementation only in the epicentre (Hubei province, China); and (3) no implementation of a universal facemask wearing policy.

FINDINGS

Regardless of different universal facemask wearing policy scenarios, facemask shortage would occur but eventually end during our prediction period (from 20 Jan 2020 to 30 Jun 2020). The duration of the facemask shortage described in the scenarios of a country-wide universal facemask wearing policy, a universal facemask wearing policy in the epicentre, and no universal facemask wearing policy were 132, seven, and four days, respectively. During the prediction period, the largest daily facemask shortages were predicted to be 589·5, 49·3, and 37·5 million in each of the three scenarios, respectively. In any scenario, an N95 mask shortage was predicted to occur on 24 January 2020 with a daily facemask shortage of 2·2 million.

INTERPRETATION

Implementing a universal facemask wearing policy in the whole of China could lead to severe facemask shortage. Without effective public communication, a universal facemask wearing policy could result in societal panic and subsequently, increase the nationwide and worldwide demand for facemasks. These increased demands could cause a facemask shortage for healthcare workers and reduce the effectiveness of outbreak control in the affected regions, eventually leading to a pandemic. To fight novel infectious disease outbreaks, such as COVID-19, governments should monitor domestic facemask supplies and give priority to healthcare workers. The risk of asymptomatic transmission and facemask shortages should be carefully evaluated before introducing a universal facemask wearing policy in high-risk regions. Public health measures aimed at improving hand hygiene and effective public communication should be considered along with the facemask policy.

The effect of maternal use of telbivudine on neonatal CD4+CD25+ regulatory T cells for the prevention of mother-to-child transmission of hepatitis B virus

Antiviral treatment could block mother-to-child transmission (MTCT) of hepatitis B virus (HBV) effectively. We examined whether maternal use of telbivudine (LdT) could decrease the proportion of CD4⁺CD25⁺ regulatory T cells and explored the immunological mechanism. A total of 89 pregnant women with HBsAg positive were enrolled, where 30 pregnant women with HBeAg negative (viral load<10⁶ IU/ml) and the other 59 pregnant women with HBeAg positive (viral load≥10⁶ IU/ml) were followed in the study. The women with high viral load were divided to the LdT-treated group where they were prescribed with 600mg LdT daily (29 cases) during the third trimester of pregnancy or to the non-treated group (30 cases) on a voluntary basis. Samples of neonates were taken for analyzing CD4⁺CD25⁺ Tregs with flow cytometric techniques. A more significant decrease in the proportion of CD4⁺CD25⁺Tregs in neonatal peripheral blood had been observed with maternal use of telbivudine (2.8%±1.1%) than those without any treatment (7.0%±1.6%, P< 0.01). None of the infants in the LdT-treated group were HBsAg positive at 7 months of age. In addition, neonates whose mothers received telbivudine had a significant improvement in cellular immune function, as indicated by the proportion of CD8⁺ T cells. For HBV carriers with high viral load, maternal use of LdT may be useful in regulating neonatal immune function involved in mother-to-child transmission of hepatitis B virus.

Intracellular activity of antimicrobial compounds used for Staphylococcus aureus nasal decolonization

Background

Staphylococcus aureus is able to invade mammalian cells during infection and was recently observed inside nasal mucosa of healthy carriers.

Objectives

To determine the intracellular activity of antimicrobial compounds used for decolonization procedures using a cell model mimicking S. aureus nasal epithelium invasion.

Patients and methods

HaCaT cells and human nasal epithelial cells (HNECs) recovered from nasal swabs of S. aureus carriers were visualized by confocal laser scanning microscopy to detect intracellular S. aureus cells. An HaCaT cell model, mimicking S. aureus internalization observed ex vivo in HNECs, was used to assess the intracellular activity against S. aureus of 21 antimicrobial compounds used for nasal decolonization, including mupirocin and chlorhexidine.

Results

HaCaT cells and HNECs were found to internalize S. aureus with the same focal pattern. Most antimicrobial compounds tested on HaCaT cells were shown to have weak activity against intracellular S. aureus. Some systemic antimicrobials, including fusidic acid, clindamycin, linezolid, minocycline, ciprofloxacin, moxifloxacin, rifampicin and levofloxacin, reduced S. aureus intracellular loads by 0.43-1.66 log cfu/106 cells compared with the control (P < 0.001). By contrast, mupirocin and chlorhexidine reduced the S. aureus intracellular load by 0.19 and 0.23 log cfu/106 cells, respectively.

Conclusions

These data indicate that most of the antimicrobial compounds used for nasal decolonization, including mupirocin and chlorhexidine, exhibit weak activity against intracellular S. aureus using the HaCaT cell model. This work emphasizes the need to better understand the role of the S. aureus intracellular reservoir during nasal colonization in order to improve decolonization procedures.