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Socha PM, Harper S, Strumpf E, Murphy KE, Hutcheon JA. Antenatal corticosteroids and newborn respiratory outcomes in twins: A regression discontinuity study. BJOG 2024; 131:1064-1071. [PMID: 38221505 DOI: 10.1111/1471-0528.17754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/18/2023] [Accepted: 12/28/2023] [Indexed: 01/16/2024]
Abstract
OBJECTIVE To estimate the effect of antenatal corticosteroids on newborn respiratory morbidity in twins. DESIGN Regression discontinuity applied to population-based birth registry data. SETTING British Columbia, Canada, 2008-2018. POPULATION Twin pregnancies admitted for birth between 31+0 and 36+6 weeks of gestation. METHODS During our study period, Canadian clinical practice guidelines recommended antenatal corticosteroid administration for imminent preterm birth up to 33+6 weeks. We used a logistic model to compare the predicted risks of our outcomes among pregnancies admitted for birth immediately before this clinical cut-point (higher probability of exposure to antenatal corticosteroids) versus immediately after it (lower probability). MAIN OUTCOME MEASURES Our primary outcome was a composite of newborn respiratory distress or in-hospital death. Our secondary outcome was a composite of newborn respiratory intervention or in-hospital death. RESULTS Among 2524 pregnancies (5035 liveborn twins), 47% of admissions before 34+0 weeks of gestation were exposed to antenatal corticosteroids but only 4.2% of admissions after this cut-point were exposed. The risk of newborn respiratory distress or in-hospital mortality increased abruptly at 34+0 weeks, corresponding to a protective effect of treatment (risk ratio [RR] 0.69, 95% CI 0.53-0.90; risk difference [RD] -12 cases per 100 births, 95% CI -20 to -4.1). There was no clear evidence for or against an effect on newborn respiratory intervention or in-hospital death (RR 0.89, 95% CI 0.70-1.13; RD -4.2 per 100, 95% CI -13 to +4.2). CONCLUSIONS Our findings provide evidence for the effectiveness of antenatal corticosteroids in preventing adverse newborn respiratory outcomes in twins.
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Affiliation(s)
- Peter M Socha
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Quebec, Canada
| | - Sam Harper
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Quebec, Canada
| | - Erin Strumpf
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Quebec, Canada
- Department of Economics, McGill University, Montréal, Quebec, Canada
| | - Kellie E Murphy
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer A Hutcheon
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
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Popovic M, Zugna D, Tilling K, Richiardi L. Regression discontinuity design for the study of health effects of exposures acting early in life. Front Public Health 2024; 12:1377456. [PMID: 38706545 PMCID: PMC11066219 DOI: 10.3389/fpubh.2024.1377456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 04/08/2024] [Indexed: 05/07/2024] Open
Abstract
Regression discontinuity design (RDD) is a quasi-experimental approach to study the causal effect of an exposure on later outcomes by exploiting the discontinuity in the exposure probability at an assignment variable cut-off. With the intent of facilitating the use of RDD in the Developmental Origins of Health and Disease (DOHaD) research, we describe the main aspects of the study design and review the studies, assignment variables and exposures that have been investigated to identify short- and long-term health effects of early life exposures. We also provide a brief overview of some of the methodological considerations for the RDD identification using an example of a DOHaD study. An increasing number of studies investigating the effects of early life environmental stressors on health outcomes use RDD, mostly in the context of education, social and welfare policies, healthcare organization and insurance, and clinical management. Age and calendar time are the mostly used assignment variables to study the effects of various early life policies and programs, shock events and guidelines. Maternal and newborn characteristics, such as age, birth weight and gestational age are frequently used assignment variables to study the effects of the type of neonatal care, health insurance, and newborn benefits, while socioeconomic measures have been used to study the effects of social and welfare programs. RDD has advantages, including intuitive interpretation, and transparent and simple graphical representation. It provides valid causal estimates if the assumptions, relatively weak compared to other non-experimental study designs, are met. Its use to study health effects of exposures acting early in life has been limited to studies based on registries and administrative databases, while birth cohort data has not been exploited so far using this design. Local causal effect around the cut-off, difficulty in reaching high statistical power compared to other study designs, and the rarity of settings outside of policy and program evaluations hamper the widespread use of RDD in the DOHaD research. Still, the assignment variables' cut-offs for exposures applied in previous studies can be used, if appropriate, in other settings and with additional outcomes to address different research questions.
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Affiliation(s)
- Maja Popovic
- Cancer Epidemiology Unit, Department of Medical Sciences, University of Turin and CPO-Piemonte, Turin, Italy
| | - Daniela Zugna
- Cancer Epidemiology Unit, Department of Medical Sciences, University of Turin and CPO-Piemonte, Turin, Italy
| | - Kate Tilling
- MRC Integrative Epidemiology Unit at the University of Bristol, University of Bristol, Bristol, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Lorenzo Richiardi
- Cancer Epidemiology Unit, Department of Medical Sciences, University of Turin and CPO-Piemonte, Turin, Italy
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Liauw J, Foggin H, Socha P, Crane J, Joseph KS, Burrows J, Lacaze-Masmonteil T, Jain V, Boutin A, Hutcheon J. Technical Update No. 439: Antenatal Corticosteroids at Late Preterm Gestation. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:445-457.e2. [PMID: 36572248 DOI: 10.1016/j.jogc.2022.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To update recommendations for administration of antenatal corticosteroids in the late preterm period. TARGET POPULATION Pregnant individuals at risk of preterm birth from 340 to 366 weeks gestation. OPTIONS Administration or non-administration of a single course of antenatal corticosteroids at 340 to 366 weeks gestation. OUTCOMES Neonatal morbidity (respiratory distress, hypoglycemia), long-term neurodevelopment, and other long-term outcomes (growth, cardiac/metabolic, respiratory). BENEFITS, HARMS, AND COSTS Administration of antenatal corticosteroids from 340 to 366 weeks gestation decreases the risk of neonatal respiratory distress but increases the risk of neonatal hypoglycemia. The long-term impacts of antenatal corticosteroid administration from 340 to 366 weeks gestation are uncertain. EVIDENCE For evidence on the neonatal effects of antenatal corticosteroid administration at late preterm gestation, we summarized evidence from the 2020 Cochrane review of antenatal corticosteroids and combined this with evidence from published randomized trials identified by searching Ovid MEDLINE from January 1, 2020, to May 11, 2022. Given the absence of direct evidence on the impact of late preterm antenatal corticosteroid administration on neurodevelopmental outcomes, we summarized evidence on the impact of antenatal corticosteroids across gestational ages on neurodevelopmental outcomes using the following sources: (1) the 2020 Cochrane review; and (2) evidence obtained by searching Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) databases from inception to January 5, 2022. We did not apply date or language restrictions. Given the absence of direct evidence on the impact of late preterm antenatal corticosteroid administration on other long-term outcomes, we summarized evidence on the impact of antenatal corticosteroids across gestational ages on other long-term outcomes by combining findings from the 2020 Cochrane review with evidence obtained by searching Ovid MEDLINE for observational studies related to long-term cardiometabolic, respiratory, and growth effects of antenatal corticosteroids from inception to October 22, 2021. We reviewed reference lists of included studies and relevant systematic reviews for additional references. See Appendix A for search terms and summaries. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix B (Tables B1 for definitions and B2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE Maternity care providers, including midwives, family physicians, and obstetricians. SUMMARY STATEMENTS RECOMMENDATIONS.
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Odden MC, Zhang A, Jawadekar N, Tan A, Moran AE, Glymour MM, Brayne C, Zeki Al Hazzouri A, Calonico S. Regression discontinuity design to evaluate the effect of statins on myocardial infarction in electronic health records. Eur J Epidemiol 2023; 38:393-402. [PMID: 36935439 DOI: 10.1007/s10654-023-00982-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 02/27/2023] [Indexed: 03/21/2023]
Abstract
Regression discontinuity design (RDD) is a quasi-experimental method intended for causal inference in observational settings. While RDD is gaining popularity in clinical studies, there are limited real-world studies examining the performance on estimating known trial casual effects. The goal of this paper is to estimate the effect of statins on myocardial infarction (MI) using RDD and compare with propensity score matching and Cox regression. For the RDD, we leveraged a 2008 UK guideline that recommends statins if a patient's 10-year cardiovascular disease (CVD) risk score > 20%. We used UK electronic health record data from the Health Improvement Network on 49,242 patients aged 65 + in 2008-2011 (baseline) without a history of CVD and no statin use in the two years prior to the CVD risk score assessment. Both the regression discontinuity (n = 19,432) and the propensity score matched populations (n = 24,814) demonstrated good balance of confounders. Using RDD, the adjusted point estimate for statins on MI was in the protective direction and similar to the statin effect observed in clinical trials, although the confidence interval included the null (HR = 0.8, 95% CI 0.4, 1.4). Conversely, the adjusted estimates using propensity score matching and Cox regression remained in the harmful direction: HR = 2.42 (95% CI 1.96, 2.99) and 2.51 (2.12, 2.97). RDD appeared superior to other methods in replicating the known protective effect of statins with MI, although precision was poor. Our findings suggest that, when used appropriately, RDD can expand the scope of clinical investigations aimed at causal inference by leveraging treatment rules from everyday clinical practice.
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Affiliation(s)
- Michelle C Odden
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA. .,Department of Epidemiology and Population Health, Stanford University School of Medicine, 1701 Page Mill Rd., Palo Alto, CA, 94304, USA.
| | - Adina Zhang
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Neal Jawadekar
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Annabel Tan
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
| | - Andrew E Moran
- Department of Medicine, Columbia University, New York, NY, USA
| | - M Maria Glymour
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Carol Brayne
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Adina Zeki Al Hazzouri
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Sebastian Calonico
- Department of Health Policy and Management, Columbia University, New York, NY, USA
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Hutcheon JA, Liauw J. Counterpoint: The value of benchmarking in observational studies of the longer term safety of antenatal corticosteroids. Paediatr Perinat Epidemiol 2023; 37:15-18. [PMID: 36482791 PMCID: PMC10107235 DOI: 10.1111/ppe.12937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/17/2022] [Accepted: 10/30/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Jennifer A Hutcheon
- Department of Obstetrics and Gynaecology, University of British Columbia, British Columbia, Vancouver, Canada
| | - Jessica Liauw
- Department of Obstetrics and Gynaecology, University of British Columbia, British Columbia, Vancouver, Canada
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Caniglia EC, Hinkle SN. Point: Benchmarking can supplement transportability to answer critical questions about the effectiveness of antenatal corticosteroid administration. Paediatr Perinat Epidemiol 2023; 37:9-11. [PMID: 35988915 DOI: 10.1111/ppe.12923] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/08/2022] [Indexed: 02/01/2023]
Affiliation(s)
- Ellen C Caniglia
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Stefanie N Hinkle
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Hutcheon JA, Liauw J. Improving the external validity of Antenatal Late Preterm Steroids trial findings. Paediatr Perinat Epidemiol 2023; 37:1-8. [PMID: 34981851 PMCID: PMC9250943 DOI: 10.1111/ppe.12856] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 12/09/2021] [Accepted: 12/19/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The external validity of randomised trials can be compromised when trial participants differ from real-world populations. In the Antenatal Late Preterm Steroids (ALPS) trial of antenatal corticosteroids at late preterm ages, participants had systematically younger gestational ages than those outside the trial setting. As risk of respiratory morbidity (the primary trial outcome) is higher at younger gestations, absolute benefits of corticosteroids calculated in the trial population may overestimate real-world treatment benefits. OBJECTIVES To estimate the real-world absolute risk reduction and number-needed-to-treat (NNT) for antenatal corticosteroids at late preterm ages, accounting for gestational age differences between the ALPS and real-world populations. METHODS Individual participant data from the ALPS trial (which recruited 2831 women with imminent preterm birth at 34+0 to 36+5 weeks') was appended to population-based data for 15,741 women admitted for delivery between 34+0 and 36+5 weeks' from British Columbia, Canada, 2000-2013. We used logistic regression to calculate inverse odds of sampling weights for each trial participant and re-estimated treatment effects of corticosteroids on neonatal respiratory morbidity in ALPS participants, weighted to reflect the gestational age distribution of the population-based (real-world) sample. RESULTS The real-world absolute risk reduction was estimated to be -2.2 (95% CI -4.6, 0.0) cases of respiratory morbidity per 100, compared with -2.8 (95% CI -5.3, -0.3) in original trial data. Corresponding NNTs were 46 in the real-world setting vs 35 in the trial. Our focus on absolute measures also highlighted that the benefits of antenatal corticosteroids may be meaningfully greater at 34 weeks vs. 36 weeks (e.g., risk reductions of -3.7 vs. -1.2 per 100 respectively). CONCLUSIONS The absolute risk reductions and NNTs associated with antenatal corticosteroid administration at late preterm ages estimated in our study may be more appropriate for patient counselling as they better reflect the anticipated benefits of treatment when used in a real-world situation.
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Affiliation(s)
- Jennifer A Hutcheon
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, Canada
| | - Jessica Liauw
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, Canada
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Mise à jour technique no 439 : Corticothérapie prénatale en période de prématurité tardive. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 45:458-472.e2. [PMID: 36572247 DOI: 10.1016/j.jogc.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Schummers L, Hutcheon JA. Study Quality Must Be Considered When Evaluating Long-term Outcomes of Antenatal Corticosteroid Therapy in Children. JAMA Pediatr 2022; 176:1048-1049. [PMID: 35969393 DOI: 10.1001/jamapediatrics.2022.2855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Laura Schummers
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jennifer A Hutcheon
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Socha P, McGee A, Bhattacharya S, Young C, Wang R. Antenatal Corticosteroids and Neonatal Outcomes in Twins. Obstet Gynecol 2022; 140:20-30. [DOI: 10.1097/aog.0000000000004835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/07/2022] [Indexed: 11/25/2022]
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Ninan K, Liyanage SK, Murphy KE, Asztalos EV, McDonald SD. Evaluation of Long-term Outcomes Associated With Preterm Exposure to Antenatal Corticosteroids: A Systematic Review and Meta-analysis. JAMA Pediatr 2022; 176:e220483. [PMID: 35404395 PMCID: PMC9002717 DOI: 10.1001/jamapediatrics.2022.0483] [Citation(s) in RCA: 63] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
IMPORTANCE Animal studies have found that antenatal corticosteroids affect many organs across multiple stages of life. However, the long-term outcomes in human children are not well understood. OBJECTIVE To conduct a systematic review and meta-analysis of long-term outcomes associated with preterm exposure to antenatal corticosteroids compared with no exposure in all children as well as children with preterm and full-term birth. DATA SOURCES Academic databases were searched for articles published from January 1, 2000, to October 29, 2021, including Ovid MEDLINE, Ovid Embase, PsycInfo, CINAHL (Cumulative Index of Nursing and Allied Health Literature), Web of Science, ClinicalTrials.gov, and Google Scholar. References of articles were also searched for relevant studies. STUDY SELECTION Randomized clinical trials (RCTs), quasi-RCTs, and cohort studies that assessed long-term neurodevelopmental, psychological, or other outcomes at 1 year or older in those who had preterm exposure to antenatal corticosteroids were included. No language restrictions were set. DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted data using a piloted data extraction form. Data on study population, pregnancy characteristics, exposure to antenatal corticosteroids, and outcomes were collected. Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guidelines were followed, and random-effects models were used for the meta-analysis. MAIN OUTCOMES AND MEASURES The primary outcome was an author-defined composite of any adverse neurodevelopmental and/or psychological disorder. The secondary outcomes included specific measures of psychological disorders; neurodevelopmental delay; and anthropometric, metabolic, and cardiorespiratory outcomes. RESULTS A total of 30 studies met the inclusion criteria, and involved more than 1.25 million children who were at least 1 year of age when the outcomes were assessed. Exposure to a single course of antenatal corticosteroids for children with extremely preterm birth was associated with a significant reduction in risk of neurodevelopmental impairment (adjusted odds ratio, 0.69 [95% CI, 0.57-0.84]; I2 = 0%; low certainty). For children with late-preterm birth, exposure to antenatal corticosteroids was associated with a higher risk of investigation for neurocognitive disorders (n = 25 668 children; adjusted hazard ratio [aHR], 1.12 [95% CI, 1.05-1.20]; low certainty). For children with full-term birth, exposure to antenatal corticosteroids was associated with a higher risk of mental or behavioral disorders (n = 641 487 children; aHR, 1.47 [95% CI, 1.36-1.60]; low certainty) as well as proven or suspected neurocognitive disorders (n = 529 205 children; aHR, 1.16 [95% CI, 1.10-1.21]; low certainty). CONCLUSIONS AND RELEVANCE Results of this study showed that exposure to a single course of antenatal corticosteroids was associated with a significantly lower risk of neurodevelopmental impairment in children with extremely preterm birth but a significantly higher risk of adverse neurocognitive and/or psychological outcomes in children with late-preterm and full-term birth, who made up approximately half of those with exposure to antenatal corticosteroids. The findings suggest a need for caution in administering antenatal corticosteroids.
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Affiliation(s)
- Kiran Ninan
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Sugee K. Liyanage
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Kellie E. Murphy
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth V. Asztalos
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Sarah D. McDonald
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada,Department of Radiology, McMaster University, Hamilton, Ontario, Canada,Division of Maternal-Fetal Medicine, McMaster University, Hamilton, Ontario, Canada
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魏 思. Recent research on the effect of common treatments given in the perinatal period on neurodevelopment in offspring. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:332-338. [PMID: 35351267 PMCID: PMC8974644 DOI: 10.7499/j.issn.1008-8830.2111002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 01/20/2022] [Indexed: 06/14/2023]
Abstract
The perinatal period is the key period for the development of brain and central nervous system, and different events in this period will have a profound influence on brain development. Glucocorticoids, antibiotics, magnesium sulfate, caffeine, pulmonary surfactant, and mild hypothermia treatment are commonly used drugs or treatment methods in the perinatal period and are closely associated with the prognosis of neonatal neurodevelopment. This article reviews the latest research on the effect of perinatal treatments on neonatal neurodevelopment, so as to provide a reference for clinical decision making.
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Lapinsky SC, Wee WB, Penner M. Timing of antenatal corticosteroids for optimal neonatal outcomes: A Markov decision analysis model. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 44:482-489. [PMID: 34749025 DOI: 10.1016/j.jogc.2021.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/21/2021] [Accepted: 10/21/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Antenatal corticosteroids (ACSs) are administered to pregnant individuals at high risk of preterm delivery to reduce neonatal morbidity and mortality. ACSs have a limited timeframe of effectiveness, and timing of administration can be difficult because of uncertainty surrounding the likelihood of preterm delivery. The objective of the current study was to design a decision analysis model to optimize the timing of ACS administration and identify important model variables that impact administration timing preference. METHODS We created a Markov decision analysis model with a base case of a patient at 240 weeks gestation with antepartum hemorrhage. Decision strategies included immediate, delayed, and no ACS administration. Outcomes were based on the neonatal perspective and consisted of lifetime quality adjusted life years (QALYs). Data for model inputs were derived from current literature and clinical recommendations. RESULTS Our base case analysis revealed a preferred strategy of delaying ACSs for 2 weeks, which maximized QALYs (39.18 lifetime discounted), driven by reduced neonatal morbidity at the expense of 0.1% more neonatal deaths, when compared with immediate ACS administration. Sensitivity analyses identified that, if the probability of delivery within the next week was >6.19%, then immediate steroids were preferred. Other important variables included gestational age, ACS effectiveness, and ACS adverse effects. CONCLUSION ACS timing involves a trade-off between morbidity and mortality, and optimal timing depends on probability of delivery, gestational age, and risks and benefits of ACSs. Clinicians should carefully consider these factors prior to ACS administration.
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Affiliation(s)
- Stephanie C Lapinsky
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON.
| | - Wallace B Wee
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON; Department of Pediatrics, Division of Respiratory Medicine, Hospital for Sick Children, Toronto, ON
| | - Melanie Penner
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON; Bloorview Research Institute, Toronto, ON; Department of Paediatrics, University of Toronto, Toronto, ON; Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON
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