A Consilience of Inductions Supports the Extended Fetuses-at-Risk Model

Pulmonary surfactant and COVID-19: A new synthesis

Chapter 1

COVID-19 pathogenesis poses paradoxes difficult to explain with traditional physiology. For instance, since type II pneumocytes are considered the primary cellular target of SARS-CoV-2; as these produce pulmonary surfactant (PS), the possibility that insufficient PS plays a role in COVID-19 pathogenesis has been raised. However, the opposite of predicted high alveolar surface tension is found in many early COVID-19 patients: paradoxically normal lung volumes and high compliance occur, with profound hypoxemia. That 'COVID anomaly' was quickly rationalised by invoking traditional vascular mechanisms-mainly because of surprisingly preserved alveolar surface in early hypoxemic cases. However, that quick rejection of alveolar damage only occurred because the actual mechanism of gas exchange has long been presumed to be non-problematic, due to diffusion through the alveolar surface. On the contrary, we provide physical chemical evidence that gas exchange occurs by an process of expansion and contraction of the three-dimensional structures of PS and its associated proteins. This view explains anomalous observations from the level of cryo-TEM to whole individuals. It encompasses results from premature infants to the deepest diving seals. Once understood, the COVID anomaly dissolves and is straightforwardly explained as covert viral damage to the 3D structure of PS, with direct treatment implications. As a natural experiment, the SARS-CoV-2 virus itself has helped us to simplify and clarify not only the nature of dyspnea and its relationship to pulmonary compliance, but also the fine detail of the PS including such features as water channels which had heretofore been entirely unexpected.

Chapter 2

For a long time, physical, colloid and surface chemistry have not intersected with physiology and cell biology as much as we might have hoped. The reasons are starting to become clear. The discipline of physical chemistry suffered from serious unrecognised omissions that rendered it ineffective. These foundational defects included omission of specific ion molecular forces and hydration effects. The discipline lacked a predictive theory of self-assembly of lipids and proteins. Worse, theory omitted any role for dissolved gases, O2, N2, CO2, and their existence as stable nanobubbles above physiological salt concentration. Recent developments have gone some way to explaining the foam-like lung surfactant structures and function. It delivers O2/N2 as nanobubbles, and efflux of CO2, and H2O nanobubbles at the alveolar surface. Knowledge of pulmonary surfactant structure allows an explanation of the mechanism of corona virus entry, and differences in infectivity of different variants. CO2 nanobubbles, resulting from metabolism passing through the molecular frit provided by the glycocalyx of venous tissue, forms the previously unexplained foam which is the endothelial surface layer. CO2 nanobubbles turn out to be lethal to viruses, providing a plausible explanation for the origin of 'Long COVID'. Circulating nanobubbles, stable above physiological 0.17 M salt drive various enzyme-like activities and chemical reactions. Awareness of the microstructure of Pulmonary Surfactant and that nanobubbles of (O2/N2) and CO2 are integral to respiratory and circulatory physiology provides new insights to the COVID-19 and other pathogen activity.

Bias in comparisons of mortality among very preterm births: A cohort study

BACKGROUND

Several studies of prenatal determinants and neonatal morbidity and mortality among very preterm births have resulted in unexpected and paradoxical findings. We aimed to compare perinatal death rates among cohorts of very preterm births (24-31 weeks) with rates among all births in these groups (≥24 weeks), using births-based and fetuses-at-risk formulations.

METHODS

We conducted a cohort study of singleton live births and stillbirths ≥24 weeks' gestation using population-based data from the United States and Canada (2006-2015). We contrasted rates of perinatal death between women with or without hypertensive disorders, between maternal races, and between births in Canada vs the United States.

RESULTS

Births-based perinatal death rates at 24-31 weeks were lower among hypertensive than among non-hypertensive women (rate ratio [RR] 0.67, 95% CI 0.65-0.68), among Black mothers compared with White mothers (RR 0.94, 95%CI 0.92-0.95) and among births in the United States compared with Canada (RR 0.74, 95%CI 0.71-0.75). However, overall (≥24 weeks) perinatal death rates were higher among births to hypertensive vs non-hypertensive women (RR 2.14, 95%CI 2.10-2.17), Black vs White mothers (RR 1.86, 95%CI 184-1.88;) and births in the United States vs Canada (RR 1.08, 95%CI 1.05-1.10), as were perinatal death rates based on fetuses-at-risk at 24-31 weeks (RR for hypertensive disorders: 2.58, 95%CI 2.53-2.63; RR for Black vs White ethnicity: 2.29, 95%CI 2.25-2.32; RR for United States vs Canada: 1.27, 95%CI 1.22-1.30).

CONCLUSION

Studies of prenatal risk factors and between-centre or between-country comparisons of perinatal mortality bias causal inferences when restricted to truncated cohorts of very preterm births.

The Effect of Prenatal Treatments on Offspring Events in the Presence of Competing Events: An Application to a Randomized Trial of Fertility Therapies

When studying the effect of a prenatal treatment on events in the offspring, failure to produce a live birth is a competing event for events in the offspring. A common approach to handle this competing event is reporting both the treatment-specific probabilities of live births and of the event of interest among live births. However, when the treatment affects the competing event, the latter probability cannot be interpreted as the causal effect among live births. Here we provide guidance for researchers interested in the effects of prenatal treatments on events in the offspring in the presence of the competing event "no live birth." We review the total effect of treatment on a composite event and the total effect of treatment on the event of interest. These causal effects are helpful for decision making but are agnostic about the pathways through which treatment affects the event of interest. Therefore, based on recent work, we also review three causal effects that explicitly consider the pathways through which treatment may affect the event of interest in the presence of competing events: the direct effect of treatment on the event of interest under an intervention to eliminate the competing event, the separable direct and indirect effects of treatment on the event of interest, and the effect of treatment in the principal stratum of those who would have had a live birth irrespective of treatment choice. As an illustrative example, we use a randomized trial of fertility treatments and risk of neonatal complications.

The fragile foundations of the extended fetuses-at-risk approach

BACKGROUND

Whether denominators for postnatal outcomes (ascertained after live birth) with a presumed prenatal origin should consist of fetuses or live births remains controversial. Proponents argue that the extended fetuses-at-risk (FAR) approach (a), provides a justification for medically indicated preterm delivery, (b), avoids paradoxical results, and (c), permits quantification of incidence of fetal-infant phenomena, such as "revealed" small for gestational age (SGA)-which, under FAR, rises with advancing gestation.

METHODS

This conceptual paper examines the validity of the above arguments.

RESULTS

As obstetricians induce babies early because of fetal (or maternal) compromise and despite the dangers posed by immaturity, there is no need to modify a paradigm that portrays preterm birth as a powerful risk factor. The FAR approach generally avoids "paradoxical" intersections because FAR rates of postnatal outcomes depend on the birth rate. However, this property, which causes rates of most postnatal outcomes to rise at term, can also lead to risk reversals and other misleading findings. The FAR formulation does not yield the incidence of postnatal conditions but, rather, the incidence of live birth (and survival to diagnosis) of babies with prevalent conditions (and, sometimes, future ones).

CONCLUSIONS

The proposed arguments do not provide adequate support for extending the FAR approach to postnatal outcomes. As only live births can contribute to the numerator of rates, the usefulness and interpretability of FAR measures in this setting are limited.

Association of Race/Ethnicity With Very Preterm Neonatal Morbidities

IMPORTANCE

Severe morbidity in very preterm infants is associated with profound clinical implications on development and life-course health. However, studies of racial/ethnic disparities in severe neonatal morbidities are scant and suggest that these disparities are modest or null, which may be an underestimation resulting from the analytic approach used.

OBJECTIVE

To estimate racial/ethnic differences in severe morbidities among very preterm infants.

DESIGN, SETTING, AND PARTICIPANTS

This population-based retrospective cohort study was conducted in New York City, New York, using linked birth certificate, mortality data, and hospital discharge data from January 1, 2010, through December 31, 2014. Infants born before 24 weeks' gestation, with congenital anomalies, and with missing data were excluded. Racial/ethnic disparities in very preterm birth morbidities were estimated through 2 approaches, conventional analysis and fetuses-at-risk analysis. The conventional analysis used log-binomial regression to estimate the relative risk of 4 severe neonatal morbidities for the racial/ethnic groups. For the fetuses-at-risk analysis, Cox proportional hazards regression with death as competing risk was used to estimate subhazard ratios associating race/ethnicity with each outcome. Estimates were adjusted for sociodemographic factors and maternal morbidities. Data were analyzed from September 5, 2017, to May 21, 2018.

MAIN OUTCOMES AND MEASURES

Four morbidity outcomes were defined using International Classification of Diseases, Ninth Revision, diagnosis and procedure codes: necrotizing enterocolitis, intraventricular hemorrhage, bronchopulmonary dysplasia, and retinopathy of prematurity.

RESULTS

In total, 582 297 infants were included in this study. Of these infants, 285 006 were female (48.9%) and 297 291 were male (51.0%). Using the conventional approach in the very preterm birth subcohort, black compared with white infants had an increased risk of only bronchopulmonary dysplasia (adjusted risk ratio [aRR], 1.34; 95% CI, 1.09-1.64) and a borderline increased risk of necrotizing enterocolitis (aRR, 1.39; 95% CI, 1.00-1.93). Hispanic infants had a borderline increased risk of necrotizing enterocolitis (aRR, 1.39; 95% CI, 0.98-1.96), and Asian infants had an increased risk of retinopathy of prematurity (aRR, 1.85; 95% CI, 1.15-2.97). In the fetuses-at-risk analysis, black infants had a 4.40 times higher rate of necrotizing enterocolitis (95% CI, 2.98-6.51), a 2.73 times higher rate of intraventricular hemorrhage (95% CI, 1.63-4.57), a 4.43 times higher rate of bronchopulmonary dysplasia (95% CI, 2.88-6.81), and a 2.98 times higher rate of retinopathy of prematurity (95% CI, 2.01-4.40). Hispanic infants had an approximately 2 times higher rate for all outcomes, and Asian infants had increased risk only for retinopathy of prematurity (adjusted hazard ratio, 2.43; 95% CI, 1.43-4.11).

CONCLUSIONS AND RELEVANCE

In this study, racial/ethnic disparities in neonatal morbidities among very preterm infants appear to be sizable, but may have been underestimated in previous studies, and may have implications for the future. Understanding these racial/ethnic disparities is important, as they may contribute to inequalities in health and development later in the child's life.

The curse of the perinatal epidemiologist: inferring causation amidst selection

Purpose of review

Human reproduction is a common process and one that unfolds over a relatively short time, but pregnancy and birth processes are challenging to study. Selection occurs at every step of this process (e.g., infertility, early pregnancy loss, and stillbirth), adding substantial bias to estimated exposure-outcome associations. Here we focus on selection in perinatal epidemiology, specifically, how it affects research question formulation, feasible study designs, and interpretation of results.

Recent findings

Approaches have recently been proposed to address selection issues in perinatal epidemiology. One such approach is the ongoing pregnancies denominator for gestation-stratified analyses of infant outcomes. Similarly, bias resulting from left truncation has recently been termed "live birth bias," and a proposed solution is to control for common causes of selection variables (e.g., fecundity, fetal loss) and birth outcomes. However, these approaches have theoretical shortcomings, conflicting with the foundational epidemiologic concept of populations at risk for a given outcome.

Summary

We engage with epidemiologic theory and employ thought experiments to demonstrate the problems of using denominators that include units not "at risk" of the outcome. Fundamental (and commonsense) concerns of outcome definition and analysis (e.g., ensuring that all study participants are at risk for the outcome) should take precedence in formulating questions and analysis approach, as should choosing questions that stakeholders care about. Selection and resulting biases in human reproductive processes complicate estimation of unbiased exposure- outcome associations, but we should not focus solely (or even mostly) on minimizing such biases.

The fetuses-at-risk approach: survival analysis from a fetal perspective

Several phenomena in contemporary perinatology create challenges for analyzing pregnancy outcomes. These include recent increases in iatrogenic delivery at late preterm and early term gestation, which are incongruent with the belief that stillbirth and neonatal death risks decrease exponentially with advancing gestational age. Perinatal epidemiologists have also puzzled over the paradox of intersecting birthweight-specific and gestational age-specific perinatal mortality curves for decades. For example, neonatal mortality rates among preterm infants of women who smoke are substantially lower than neonatal mortality rates among preterm infants of non-smoking women, whereas the reverse pattern occurs at term gestation. This mortality crossover is observed across several contrasts (for example, women with hypertensive disorders of pregnancy vs. normotensive women, older vs. younger women, twins vs. singletons) and outcomes (stillbirth, neonatal death, sudden infant death syndrome and cerebral palsy), and irrespective of how advancing "maturity" is defined (birthweight or gestational age). One approach proposed to address and explain these unexpected phenomena is the fetuses-at-risk model. This formulation involves a reconceptualization of the denominator for perinatal outcome rates from births to surviving fetuses. In this overview of the fetuses-at-risk model, we discuss the central tenets of the births-based and the fetuses-based formulations. We also describe the extension of the fetuses-at-risk approach to outcomes into and beyond the neonatal period and to a multivariable adaptation. Finally, we provide a substantive context by discussing biological mechanisms underlying the fetuses-at-risk model and contemporary obstetric phenomena that are better understood from that model than from one based on births.

Methodological Challenges in International Comparisons of Perinatal Mortality

PURPOSE OF REVIEW

Several prestigious agencies routinely rank countries based on crude perinatal and infant mortality rates, while more recently, international neonatal networks have begun comparing neonatal mortality and morbidity rates among very preterm and very low-birth-weight infants. We discuss the methodologic challenges that compromise such comparisons and potential remedies.

RECENT FINDINGS

Crude perinatal mortality rates are biased by international variations in birth registration, especially at the borderline of viability. Such bias is demonstrated by significant differences in crude versus birth weight- and gestational age-specific comparisons of perinatal mortality. Comparisons of neonatal mortality among very preterm and very low-birth-weight infants are plagued by incorrect denominators, and this leads to paradoxical findings.

SUMMARY

A lack of standardization with regard to birth registration and inadequate appreciation of the methods for calculating gestational age-specific mortality rates are responsible for biasing international comparisons of perinatal mortality.