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Supplementary Information
The online version contains supplementary material available at 10.1186/s12879-023-08297-7.
PMC10594805
Keywords
PMC10594805
Background
death, VTE, respiratory syndrome, bleeding
CORONAVIRUS DISEASE 19, BLEEDING, ARTERIAL THROMBOSIS
Governments and health official worldwide are still facing the challenge of the severe respiratory syndrome epidemic due to the Coronavirus Disease 19 (COVID-19) [Studies in ICU patients, such as the INSPIRATION trial, showed no benefit of intermediate doses of LMWH when compared with standard-dose prophylaxis, on the ...
PMC10594805
Methods
PMC10594805
Experimental design
A non-randomized parallel assignment study was conducted with two arms: a phase II single-arm interventional study including all patients treated with the study drug and an observational cohort including all patients screened for receiving the study drug but not included in the phase II study.
PMC10594805
Objectives
The primary objective was to analyze the safety of intermediate weight adjusted enoxaparin in hospitalized patients with moderate-severe COVID-19. Secondary objective was to investigate the efficacy of intermediate weight adjusted enoxaparin in improving the clinical outcome of hospitalized patients with moderate-sever...
PMC10594805
Setting
The study INHIXACOVID19 was conducted in 13 Italian centers (see Supplementary Table
PMC10594805
Study population
bleeding, arteriovenous malformations, vascular aneurysms, malignant tumors, venous thromboembolism, hypersensitivity
BLEEDING, HEMORRHAGIC STROKE, DISEASE, COVID-19 INFECTION, MALIGNANT TUMORS, PEPTIC ULCER, COAGULOPATHY, HEPARIN INDUCED THROMBOCYTOPENIA, ATRIAL FIBRILLATION, HYPERSENSITIVITY, IMPAIRED RENAL FUNCTION
The same inclusion and exclusion criteria were applied for patients included either in the interventional or in the observational arms. Inclusion criteria were: age >  = 18 y; hospital admission; microbiologically confirmed COVID-19 infection; moderate-severe disease according to study definitions (see below); and abil...
PMC10594805
Clinical severity definitions
respiratory failure, pneumonia, fever
RESPIRATORY FAILURE, PNEUMONIA, MULTIPLE ORGAN FAILURE, SEPTIC SHOCK
Clinical severity of COVID-19 was assessed at the time of diagnosis, during the treatment with the study drug, and at the end of treatment according to the following criteria [Mild: only mild symptoms without radiographic featuresModerate: fever, respiratory symptoms, and radiographic signs of pneumoniaSevere: fever, r...
PMC10594805
Treatments
EMA
Patients included in the observational cohort received standard thromboprophylaxis with enoxaparin 40 mg od, while patients included in the interventional cohort received subcutaneous enoxaparin in a single daily dose of:60 mg (body weight of 45–60 kg)80 mg (body weight of 61–100 kg)100 mg (body weight > 100 kg)The int...
PMC10594805
Laboratory tests
VIRUS, HEPARIN INDUCED THROMBOCYTOPENIA
After reaching the steady state (usually after the third dose), heparin levels were measured with the determination of anti-Xa activity on a blood sample obtained at 4 h after the morning injection. LMWH dose could then be increased or reduced according anti-FXa (anti-Xa) activity (0.4–0.6 anti-Xa UI/ml for intermediat...
PMC10594805
Follow-up
Follow-up was 90 days after study drug initiation. Follow-up information was collected via telephone calls, patient medical records and/or clinical visits according to clinical evolution.
PMC10594805
Outcomes
pulmonary embolism, stroke, bleeding
PULMONARY EMBOLISM, ACUTE MYOCARDIAL INFARCTION, BLEEDING, THROMBOEMBOLIC EVENT, DEEP VEIN THROMBOSIS (DVT), ADVERSE EVENTS, STROKE, COMPLICATIONS
Primary outcome was the rate of adverse events (AEs) in particular bleeding complications during treatment, at the end of treatment (EOT) and at 30 days after EOT, and occurrence of thromboembolic event at 90 days after COVID-19 diagnosis. Symptomatic thromboembolic events were objectively confirmed deep vein thrombosi...
PMC10594805
Outcome assessment
thromboembolic, death, bleeding
EVENTS, BLEEDING
The cause of death was evaluated by an independent adjudication safety committee. The evolution of the clinical severity during treatment was assessed by the attending physician. All outcomes related to thromboembolic and bleeding events were assessed by an independent adjudication safety committee with an interim safe...
PMC10594805
Sample size determination
This was a pilot study and an initial sample of 100 patients for the phase II single-arm interventional trial was established.
PMC10594805
Statistical analyses
Binary variables, such as the presence/absence of a given underlying condition, were reported as raw number and prevalence rates along with the
PMC10594805
Results
PMC10594805
Analysis of safety
Bleeding, bleeding, venous thrombosis
PULMONARY EMBOLISM, BLEEDING, THROMBOEMBOLIC EVENT, BLEEDING, EVENTS, VENOUS THROMBOSIS
The bleeding events within 30 days were 5.4% and 0.5% in the interventional and in the observational arms (Bleeding and thromboembolic events in the interventional and observational cohortsAt 30 days, four patients in the observational cohort had a thromboembolic event; of these two were venous thrombosis and two were ...
PMC10594805
Analysis of efficacy
hypertension, COPD, diabetes
DISEASE, COPD, EVENTS, HYPERTENSION, DIABETES
Crude comparison of outcome variables between interventional and observational arms are shown in supplementary Table To account for differences in the two groups, a propensity score matching algorithm was done identifying a match for 90 patients both in the interventional and observational cohort, based on age, gender,...
PMC10594805
Discussion
bleeding, thromboembolic, DVT, thrombotic, VTE
BLEEDING, MINOR, EVENT, DEEP VEIN THROMBOSES, ADVERSE EVENT, BLIND, EVENTS, COMPLICATIONS, DVT
This phase II pilot study showed that thromboprophylaxis with intermediate dose heparin with anti-FXa monitoring in patients with moderate or severe COVID-19 and moderately increased D-dimer was not associated with a higher risk of major bleeding compared to patients receiving standard dose prophylaxis. Indeed, there w...
PMC10594805
Conclusions
BLEEDING
Intermediate dose heparin with anti-Factor Xa monitoring in patients with moderate or severe COVID-19 and moderately increased D-dimer was not associated with an increased risk of major bleeding. Our data seems to suggest a more favorable clinical course and shorter length of hospitalization in patients treated with in...
PMC10594805
Authors’ contributions
P.
B. Cosmi, F. Drago, M. Giannella, A. Stella and P. Viale designed the study, managed and coordinated responsibility for research activity planning and execution and wrote the draft; A. Romagnoli managed activities to annotate (produce metadata), scrub data and maintain research data (including software code, where it i...
PMC10594805
Funding
No funding.
PMC10594805
Availability of data and materials
The datasets generated and/or analysed during the current study are not publicly available due to local privacy policy but are available from the corresponding author on reasonable request.
PMC10594805
Declarations
PMC10594805
Ethics approval and consent to participate
INFECTIOUS DISEASES
The study was approved by the Ethics Committee of the Lazzaro Spallanzani National Institute for Infectious Diseases of Rome which has been attributed the role of National Ethics Committee for assessing clinical trials on medicines for human use and medical devices for patients with COVID-19 and by the Italian Drug Age...
PMC10594805
Consent for publication
Not applicable.
PMC10594805
Competing interests
Werfen; A. Castagna
EVENTS
B. Cosmi received speakers honoraria by Sanofi, Werfen IL, fees for advisory board from Viatris and Techdow Pharma Italy; E. Grandone received payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Sanofi, ItalFarmaco, Rovi, Stago Werfen; A. Castagna received c...
PMC10594805
References
PMC10594805
Key Points
PMC10509729
Question
Is use of artificial intelligence (AI) in a simulated surgical skills curriculum associated with unintended performance outcomes?
PMC10509729
Findings
tumor, tissue damage
TUMOR
This cohort study of 46 medical students and 14 experts found that the AI-enhanced simulation curriculum demonstrated significant unintended changes in 52 performance metrics outside the curriculum that were not observed in the control cohort. These unintended changes included significantly improved procedural safety (...
PMC10509729
Meaning
SECONDARY
This cohort study found that use of AI in designing a simulated surgical skills curriculum was associated with unintended learning outcomes, with both positive and negative consequences for learner competency, suggesting that intervention from human experts may be required to optimize educational goals.This cohort stud...
PMC10509729
Importance
To better elucidate the role of artificial intelligence (AI) in surgical skills training requires investigations in the potential existence of a hidden curriculum.
PMC10509729
Objective
To assess the pedagogical value of AI-selected technical competencies and their extended effects in surgical simulation training.
PMC10509729
Design, Setting, and Participants
MAY, SECONDARY
This cohort study was a follow-up of a randomized clinical trial conducted at the Neurosurgical Simulation and Artificial Intelligence Learning Centre at the Montreal Neurological Institute, McGill University, Montreal, Canada. Surgical performance metrics of medical students exposed to an AI-enhanced training curricul...
PMC10509729
Exposure
Performance assessment and personalized feedback by an intelligent tutor on 4 AI-selected learning objectives during simulation training.
PMC10509729
Main Outcomes and Measures
Outcomes of interest were unintended performance outcomes, measured by significant within-participant difference from baseline in 270 performance metrics in the intervention cohort that was not observed in the control cohort.
PMC10509729
Results
tumor
TUMOR
A total of 46 medical students (median [range] age, 22 [18-27] years; 27 [59%] women) and 14 surgeons (median [range] age, 45 [35-59] years; 14 [100%] men) were included in this study, and no participant was lost to follow-up. Feedback on 4 AI-selected technical competencies was associated with additional performance c...
PMC10509729
Conclusions and Relevance
In this cohort study of medical students, an AI-enhanced curriculum for bimanual surgical skills resulted in unintended changes that improved performance in safety but negatively affected some efficiency metrics. Incorporating AI in course design requires ongoing assessment to maintain transparency and foster evidence-...
PMC10509729
Introduction
In surgical education, technical competency is one of the key factors of efficacy in the curriculum, and it is an independent factor that is directly associated with postoperative patient outcomes.Simulation is an important component of competency-based medical education.In our previous work,To assess the pedagogical v...
PMC10509729
Methods
PMC10509729
Study Participants
SECONDARY
We conducted a planned secondary analysis using retrospective data from 2 previously conducted studies, a cohort study of 14 experts and a randomized clinical trial involving 46 medical students. In the first study, skilled consultants performed a simulated neurosurgical procedure with no feedback to establish expert b...
PMC10509729
Study Procedure and Simulation
tumor
TUMOR
All participant performed 5 simulated neurosurgical tumor resection procedures within a fixed time and either received an intervention (VOA group) or no intervention (control and skilled groups) after the completion of each attempt.
PMC10509729
Performance Metric Extraction and Expertise Benchmarks
tumor
TUMOR
Raw data from the initial and final attempts were used to extract 270 assessment metrics for each procedure. These metrics were selected based on their ability to differentiate experts from novices and are equally divided into 3 groups depending on the state of the operation: during tumor resection, while suctioning bl...
PMC10509729
Statistical Analysis
Collected data were examined for normality with the Shapiro-Wilk test, and Wilcoxon rank test was used when
PMC10509729
Results
All 46 medical students (median [range] age, 22 [18-27] years; 27 [59%] women) and 14 surgeons (median [range] age, 45 [35-59] years; 14 [100%] men) completed the trial, and no one was lost to follow-up. Medical students were in the preclinical period of their studies (19 students [41%] in premedicine program; 16 stude...
PMC10509729
Demographic Characteristics of Participants
Abbreviations: AI, artificial intelligence; NA, not applicable.Range, 1 to 5, with higher scores indicating greater motivation to pursue a surgical specialty in postgraduate training.Participants in the VOA group responded successfully to performance feedback and achieved expert benchmarks in the curriculum’s learning ...
PMC10509729
Performance in the Learning Objectives of the Virtual Operative Assistant (VOA) Curriculum
tumor
TUMOR
The skilled group’s mean and SD in each metric are represented by the solid and dashed lines, respectively. Because the variables are recorded at a frequency of 50 Hz by the simulator, each unit of time (t) is equal to 20 ms. Error bars indicate 95% CIs.Damage to healthy brain tissue is an important safety metric in ne...
PMC10509729
Extended Associations of the Virtual Operative Assistant (VOA) Curriculum With Safety Competencies
tumor
TUMOR
The skilled group’s mean and SD in each metric are represented by the solid and dashed lines, respectively. Because the variables are recorded at a frequency of 50 Hz by the simulator, each unit of time (t) is equal to 20 ms. Error bars indicate 95% CIs.Two other important metrics of safety are maintaining a focused bi...
PMC10509729
Extended Associations of the Virtual Operative Assistant (VOA) Curriculum With Movement and Efficiency Metrics
tumor
TUMOR
The skilled group’s mean and SD in each metric are represented by the solid and dashed lines, respectively. Because the variables are recorded at a frequency of 50 Hz by the simulator, each unit of time (t) is equal to 20 ms. Error bars indicate 95% CIs.Finally, we looked at the rate of tumor resection over the entire ...
PMC10509729
Discussion
tumor, tissue damage
TUMOR
This cohort study is the first study to demonstrate unintended surgical skill acquisition with both positive and negative consequences following an AI-enhanced curriculum, to our knowledge. In the competency-based framework of postgraduate medical training, AI provides a tool to identify and teach quantifiable metrics ...
PMC10509729
Future Directions
ADVERSE EVENTS
With advancements in live intraoperative data acquisition for quality improvement, AI systems are believed to play a key role in mitigating adverse events and suggesting instructions in the operating room.
PMC10509729
Limitations
This study has some limitations. One limitation is the number of surgeons in the skilled group and their range of experience in neuro-oncological surgery. However, most participants in the skilled group primarily practiced cranial neurosurgery, and subpial resection is a fundamental technique that is mastered throughou...
PMC10509729
Conclusion
This cohort study found that learning bimanual surgical skills in simulation with metric-specific instructions on AI-selected competencies was associated with unintended changes in other competency domains. These extrinsic outcomes had both positive and negative associations with learners’ expertise level compared with...
PMC10509729
Zora Kesich
(MPH) is a graduate of the Emory University Rollins School of Public Health, Department of Behavioral, Social, & Health Education Sciences; her focus areas include harm reduction, safer consumption, and qualitative methods.
PMC10636969
Umedjon Ibragimov
(PhD, MPH) is a Research Assistant Professor in the Emory University Rollins School of Public Health; his key research areas include structural determinants of HIV/AIDS and implementation of harm reduction services in the U.S. and globally.
PMC10636969
Kelli Komro
(PhD, MPH) is a Professor jointly appointed in the Rollins School of Public Health Department of Behavioral, Social, & Health Education Sciences and Department of Epidemiology; her focus areas include child and adolescent health and reducing health disparities driven by racial and economic inequities.
PMC10636969
Kenneth Lane
of the University of Kentucky College of Public Health Department of Epidemiology was a CARE2HOPE Project Coordinator and delivered intervention sessions to participants.
PMC10636969
Melvin Livingston
(PhD) is a Research Associate Professor in the Rollins School of Public Health Department of Behavioral, Social, & Health Education Sciences; his expertise is in the application of quasi-experimental design principles to the evaluation of community interventions and state policies.
PMC10636969
April Young
(PhD, MPH) is a Professor in the University of Kentucky College of Public Health in the Department of Epidemiology and a Faculty Associate with the Center on Drug and Alcohol Research; her expertise includes substance use, social network analysis, rural health, and community engagement.
PMC10636969
Hannah L. F. Cooper
DISORDER
(ScD) is the Rollins School of Public Health Chair in Substance Use Disorder Research and a Professor jointly appointed in the school’s Department of Behavioral, Social, & Health Education Sciences and Department of Epidemiology; her areas of expertise include studying the social determinants of drug-related harms, wit...
PMC10636969
Background
Overdoses, Overdose, overdose
Overdoses have surged in rural areas in the U.S. and globally for years, but harm reduction interventions have lagged. Overdose education and naloxone distribution (OEND) programs reduce overdose mortality, but little is known about people who use drugs’ (PWUD) experience with these interventions in rural areas. Here, ...
PMC10636969
Methods
Twenty-nine one-on-one, semi-structured qualitative interviews were conducted with rural PWUD engaged in the CARE2HOPE OEND intervention in Appalachian Kentucky. Interviews were conducted via Zoom, audio-recorded, and transcribed verbatim. Thematic analysis was conducted, guided by the Rural Risk Environment Framework.
PMC10636969
Results
overdose
Participants’ naloxone experiences were shaped by all domains of their rural risk environments. The OEND intervention transformed participants’ roles locally, so they became an essential component of the local rural healthcare environment. The intervention provided access to naloxone and information, thereby increasing...
PMC10636969
Supplementary Information
The online version contains supplementary material available at 10.1186/s12954-023-00900-z.
PMC10636969
Keywords
PMC10636969
Background
Overdose, overdose
EVENTS, EVENT
Overdose burden is elevated in the United States’ rural communities [Much of what we know about how PWUD perceive and engage with naloxone comes from studies in urban and suburban areas [While these studies provide valuable insight, there remain several areas for growth in this body of research. First, there is a pauci...
PMC10636969
Methods
PMC10636969
Overview & design
overdose
All participants in this sample were part of a parent study, This qualitative sub-study, nested within the larger C2H study described above, used in-depth, semi-structured interviews to explore participant perceptions of the intervention. The current analysis focuses on data relevant to perceptions of the OEND componen...
PMC10636969
Sample & recruitment
arrest, overdose
RECRUITMENT, ARREST
Individuals were eligible for C2H if they lived in one of the Kentucky counties targeted by the study; were 18 years old or older; had been engaged in the criminal-legal system in the past 30 days prior to enrollment screening; and either used opioids to get high or injected drugs to get high 30 days prior to criminal ...
PMC10636969
Data collection
In-depth, semi-structured interviews were conducted with all participants between March 18th, 2022, and October 24th, 2022 ($30 honorarium, provided via a Western Union card). Interviews took place over a HIPAA-protected Zoom interface and lasted between 30 and 94 min. Participants without access to private space and/o...
PMC10636969
Ethics
The study was approved by the University of Kentucky IRB (#52439). Prior to all interviews, oral informed consent was obtained. All recordings, transcripts, and other study materials were stored on secure, password-protected devices.
PMC10636969
Results
The final sample for this study included 29 participants (see Table Results Visual Model
PMC10636969
Accessing/accepting naloxone
PMC10636969
Carrying naloxone
Approximately two-thirds (n = 19) of participants opted to carry naloxone at least some of the time. The C2H OEND impacted participants’ experiences of carrying naloxone by, (a) providing access to naloxone, (b) increasing participant confidence in their legal right to carry naloxone, (c) mitigating impact of police st...
PMC10636969
Safer with naloxone: “you never know when you can run into someone that is overdosing”
While interviewers did not directly query about perceived safety, several participants (n = 10) independently volunteered that despite potential consequences, they felt safer with naloxone than they did without it. No participants described feeling You can't ever tell in wherever you're at, what kind of situations goin...
PMC10636969
Helper role: “it feels good to have a part in something”
overdose
SAID
Regarding the “People would always come running to us when they would need [Narcan], when people would OD. We actually saved eight or nine, 10 lives. People would OD, we would be the ones to have the Narcan. Everywhere we go, we got Narcan. People we don't know, we have saved their lives with Narcan […] Just because we...
PMC10636969
Stigma and criminal-legal systems: “wear a badge, they think they’re better than everyone else”
overdose, arrest, trauma
ARREST
Stigma codified and perpetuated by law enforcement obstructed some participants’ comfort with carrying naloxone. Because all participants were criminal-legal system involved, relationships with law enforcement were rooted in prior conflict and experienced trauma. Several participants (n = 5) described law enforcement s...
PMC10636969
Administering naloxone
overdose
EVENT
Over half (n = 16) of participants described recent experience administering C2H-provided naloxone. Fourteen participants administered C2H-provided naloxone on someone else, one participant had C2H-provided naloxone administered on her, and one participant handed someone else the naloxone to administer to another indiv...
PMC10636969
Recipient reaction: “now they’re sober and they’re broke”
anger, overdose, adverse recipient reaction
WASTED, SAID
Participants expressed that when they used naloxone to reverse someone’s overdose, they were often met with anger and frustration upon the recipient’s revival. Participants offered various explanations for these reactions, including loss of high, acute withdrawal symptoms, and frustration of having spent limited funds ...
PMC10636969
Prior communication: “wait three minutes before you Narcan me”
Participants’ Another component of these conversations was the recipient’s communicated desire, or lack thereof, to receive naloxone. Participants described receiving or giving instructions to wait for a specified benchmark or time limit before administering naloxone. These conversations often involved one party’s inte...
PMC10636969
Discussion
overdose
This study qualitatively assessed the pathways through which risk environments influence how rural PWUD accept, carry, and administer naloxone, and the role of an OEND intervention on these experiences. Analyses found that the C2H OEND intervention altered some participants’ healthcare environments by providing access ...
PMC10636969
Accessing/Accepting naloxone
Other studies conducted in non-rural settings identified For many participants, decisions to accept naloxone were predicated not only on understanding what naloxone was and learning about its effectiveness, but also on learning about protections offered by the state’s medical amnesty/Good Samaritan policies. These crim...
PMC10636969
Carrying naloxone
overdose
Previous studies conducted in both urban and rural areas identified feelings of purpose and empowerment [Our findings identified that participants’ rural physical environments often facilitated their desire to carry naloxone, highlighting the high prevalence of overdose in their community combined with slow emergency r...
PMC10636969
Administering naloxone
Our findings highlight fear of disrupting someone’s high and fear of imposed economic loss as paired barriers to naloxone administration decisions. Previous studies in urban areas identified fear of recipient reaction and fear of disrupting someone’s high [
PMC10636969
Strengths & limitations
overdose, fatigue
EVENTS, RECRUITMENT
Results of this study fill a gap in the literature regarding naloxone experiences of PWUD in rural Appalachian communities. Furthermore, our study explored the ways that PWUD discuss naloxone with their social networks, before, during, and after overdose events. This focus area yielded rich data, providing meaningful c...
PMC10636969
Conclusion
anger, overdose
EVENT
Factors that influence rural PWUDs’ decisions to accept, carry, and administer naloxone are complex and touch upon all domains of their rural risk environment. Our sample included participants who had never heard of naloxone or had gaps in their understanding of its effectiveness and/or how to administer it. The C2H in...
PMC10636969
Acknowledgements
Overdose, overdose
RECRUITMENT
We are grateful to KORE (Kentucky Overdose Response Effort) for providing naloxone to the project. We are grateful Dr. Patricia Freeman for creating the overdose education and naloxone distribution protocol and materials, and for training the team in both. We are grateful to Dr. Michelle Lofwall for executing the stand...
PMC10636969
Author contributions
RECRUITMENT
ZK contributed to recruitment, data collection, conceptualization of the research project, iterative revision of the interview guide, development and revision of the codebook, coding, thematic analysis, and development of the paper. HC and AY were both PIs of CARE2HOPE, the larger research project under which this stud...
PMC10636969
Funding
ABUSE
This research has been supported by National Institute on Drug Abuse (NIDA) (4UH3DA044798-03; PIs: Young and Cooper).
PMC10636969
Availability of data and materials
The interview transcripts are not publicly available for confidentiality reasons.
PMC10636969
Declarations
PMC10636969
Ethics approval and consent to participate
The study was approved by the University of Kentucky IRB (#52439). Prior to all interviews, oral informed consent was obtained. All recordings, transcripts, and other study materials were stored on secure, password-protected devices. The ClinicalTrials.gov ID for the CARE2HOPE intervention is NCT04134767. The registrat...
PMC10636969
Consent for publication
Not Applicable.
PMC10636969
Competing interests
The authors declare that they have no competing interests.
PMC10636969
References
PMC10636969
1. Introduction
obesity, −2.7, gestational diabetes, ’, macrosomia, Weight loss, congenital anomalies, weight gain, overweight or obesity, 3rd-trimester, weight loss
OBESITY, GESTATIONAL DIABETES, HYPERTENSIVE DISORDER, COMPLICATIONS, PREECLAMPSIA
Preconception obesity is associated with adverse pregnancy outcomes and deprivation. The postnatal period provides an opportunity for preconception intervention. There is a lack of published postnatal behaviour and weight data to inform intervention needs. Secondary analysis of the GLOWING study explored postnatal diet...
PMC10490453
2. Materials and Methods
obesity
OBESITY, SECONDARY
A secondary analysis of data collected as part of the GLOWING pilot trial was undertaken. GLOWING was developed to support midwives’ implementation of UK guidelines for weight management during pregnancy; full details of the intervention are published elsewhere [The northeast of England has a high prevalence of both de...
PMC10490453
2.1. Socio-Demographic Data Collection
obesity
OBESITY
The socio-demographic questions include both quantitative and free-text items relating to the women’s 1st trimester BMI, ethnic group, employment, marital, smoking, and breastfeeding status, alcohol intake, and dietary preference. Women’s 1st trimester BMI were collected from electronic health records and used to categ...
PMC10490453