Ambulatory human chorionic gonadotrophin (hCG) testing: a verification of two hCG point of care devices

OBJECTIVES

Quantitative human chorionic gonadotropin (hCG) measurements are used to manage women classified with a pregnancy of unknown location (PUL). Two point of care testing (POCT) devices that quantify hCG are commercially available. We verified the i-STAT 1 (Abbott) and the AQT 90 FLEX (Radiometer) prior to use in PUL triage.

METHODS

Tests for precision, external quality assurance (EQA), correlation, hook effect and recovery were undertaken alongside a POCT usability assessment during this prospective multi-center verification.

RESULTS

Coefficients of variation ranged between 4.0 and 5.1 % for the three i-STAT 1 internal quality control (IQC) solutions and between 6.8 and 7.3 % for the two AQT IQC solutions. Symmetric differences in POCT EQA results when compared with laboratory and EQA stock values ranged between 3.2 and 24.5 % for the i-STAT 1 and between 3.3 and 36.9 % for the AQT. Correlation coefficients (i-STAT 1: 0.96, AQT: 0.99) and goodness of fit curves (i-STAT 1: 0.92, AQT: 0.99) were excellent when using suitable whole blood samples. An hCG hook effect was noted with the i-STAT 1 between 572,194 and 799,089 IU/L, lower than the hook effect noted with the AQT, which was between 799,089 and 1,619,309 IU/L. When hematocrit concentration was considered in sample types validated for use with each device, hCG recovery was 108 % with the i-STAT 1 and 98 % with the AQT. The i-STAT 1 scored lower on usability overall (90/130) than the AQT (121/130, p<0.001, Mann-Whitney).

CONCLUSIONS

Both hCG POCT devices were verified for use in clinical practice. Practical factors must also be considered when choosing which device to use in each unit.

Updating M6 pregnancy of unknown location risk-prediction model including evaluation of clinical factors

OBJECTIVES

Ectopic pregnancy (EP) is a major high-risk outcome following a pregnancy of unknown location (PUL) classification. Biochemical markers are used to triage PUL as high vs low risk to guide appropriate follow-up. The M6 model is currently the best risk-prediction model. We aimed to update the M6 model and evaluate whether performance can be improved by including clinical factors.

METHODS

This prospective cohort study recruited consecutive PUL between January 2015 and January 2017 at eight units (Phase 1), with two centers continuing recruitment between January 2017 and March 2021 (Phase 2). Serum samples were collected routinely and sent for β-human chorionic gonadotropin (β-hCG) and progesterone measurement. Clinical factors recorded were maternal age, pain score, bleeding score and history of EP. Based on transvaginal ultrasonography and/or biochemical confirmation during follow-up, PUL were classified subsequently as failed PUL (FPUL), intrauterine pregnancy (IUP) or EP (including persistent PUL (PPUL)). The M6 models with (M6P ) and without (M6NP ) progesterone were refitted and extended with clinical factors. Model validation was performed using internal-external cross-validation (IECV) (Phase 1) and temporal external validation (EV) (Phase 2). Missing values were handled using multiple imputation.

RESULTS

Overall, 5473 PUL were recruited over both phases. A total of 709 PUL were excluded because maternal age was < 16 years or initial β-hCG was ≤ 25 IU/L, leaving 4764 (87%) PUL for analysis (2894 in Phase 1 and 1870 in Phase 2). For the refitted M6P model, the area under the receiver-operating-characteristics curve (AUC) for EP/PPUL vs IUP/FPUL was 0.89 for IECV and 0.84-0.88 for EV, with respective sensitivities of 94% and 92-93%. For the refitted M6NP model, the AUCs were 0.85 for IECV and 0.82-0.86 for EV, with respective sensitivities of 92% and 93-94%. Calibration performance was good overall, but with heterogeneity between centers. Net Benefit confirmed clinical utility. The change in AUC when M6P was extended to include maternal age, bleeding score and history of EP was between -0.02 and 0.01, depending on center and phase. The corresponding change in AUC when M6NP was extended was between -0.01 and 0.03. At the 5% threshold to define high risk of EP/PPUL, extending M6P altered sensitivity by -0.02 to -0.01, specificity by 0.03 to 0.04 and Net Benefit by -0.005 to 0.006. Extending M6NP altered sensitivity by -0.03 to -0.01, specificity by 0.05 to 0.07 and Net Benefit by -0.005 to 0.006.

CONCLUSIONS

The updated M6 model offers accurate diagnostic performance, with excellent sensitivity for EP. Adding clinical factors to the model improved performance in some centers, especially when progesterone levels were not suitable or unavailable. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Beta-human chorionic gonadotrophin point of care testing for the management of pregnancy of unknown location

RESEARCH QUESTION

Does a commercially available quantitative beta-human chorionic gonadotrophin (BHCG) point of care testing (POCT) device improve workflow management in early pregnancy by performing comparably to gold standard laboratory methods, and is the performance of a validated pregnancy of unknown location (PUL) triage strategy maintained using POCT BHCG results?

DESIGN

Women classified with a PUL between 2018 and 2021 at three early pregnancy units were included. The linear relationship of untreated whole-blood POCT and serum laboratory BHCG values was defined using coefficients and regression. Paired serial BHCG values were then incorporated into the validated M6 multinomial logistic regression model to stratify the PUL as at high risk or at low risk of clinical complications. The sensitivity and negative predictive value were assessed. The timings required for equivocal POCT and laboratory care pathways were compared.

RESULTS

A total of 462 PUL were included. The discrepancy between 571 laboratory and POCT BHCG values was -5.2% (-6.2 IU/l), with a correlation coefficient of 0.96. The 133 PUL with paired 0 and 48 h BHCG values were compared using the M6 model. The sensitivity for high-risk outcomes (96.2%) and negative predictive values (98.5%) was excellent for both. Sample receipt and laboratory processing took 135 min (421 timings), compared with 12 min (91 timings) when using POCT (P < 0.0001).

CONCLUSIONS

POCT BHCG values correlated well with laboratory testing measurements. The M6 model retained its performance when using POCT BHCG values. Using the model with POCT may improve workflow and patient care without compromising on effective PUL triage.

Time-effectiveness and convenience of transvaginal ultrasound probe disinfection using ultraviolet vs chlorine dioxide multistep wipe system: prospective survey study

OBJECTIVES

To compare the efficiency, ease of use and user satisfaction of two methods of transvaginal ultrasound probe high-level disinfection: ultraviolet-C radiation (UV-C) and a chlorine dioxide multistep wipe system.

METHODS

This was a prospective survey study. UV-C units were introduced into a busy early pregnancy assessment service and compared with a multiwipe system for disinfection. Before seeing each patient, healthcare professionals (HCPs) measured with a stopwatch the time taken to complete a cycle of disinfection using either UV-C or chlorine dioxide multistep wipes and responded to a quick-response (QR) code-linked survey. Additional essential tasks that could be completed before seeing the next patient during probe disinfection were also documented. Using another QR code-linked survey, data on ease of use, satisfaction with the system used and preferred system were collected. The ease of use and satisfaction with the system were rated on a 0 to 10 Likert scale (0 poor, 10 excellent). A free-text section for comments was then completed.

RESULTS

Disinfection using UV-C (n = 331) was 60% faster than the chlorine dioxide multiwipe system (n = 332) (101 vs 250 s; P < 0.0001). A greater number of tasks were completed during probe disinfection when using UV-C, saving a further 74 s per patient (P < 0.0001). The HCPs using UV-C (n = 71) reported greater ease of use (median Likert score, 10 vs 3; P < 0.0001) and satisfaction (median Likert score, 10 vs 2; P < 0.0001) compared with those using the multiwipe system (n = 43). HCPs reported that the chlorine dioxide system was time-consuming and environmentally unfriendly, while the UV-C system was efficient and easy to use. Overall, 98% of the HCPs preferred using the UV-C system.

CONCLUSIONS

UV-C technology is more time-efficient and allows more essential tasks to be completed during disinfection. For a 4-h ultrasound list of 15 patients, the use of UV-C would save 55 min 45 s. HCPs found UV-C preferable and easier to use. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Experiences and well-being of healthcare professionals working in the field of ultrasound in obstetrics and gynaecology as the SARS-CoV-2 pandemic were evolving: a cross-sectional survey study

OBJECTIVE

Assess experience of healthcare professionals (HCPs) working with ultrasound in obstetrics and gynaecology during the evolving SARS-CoV-2 pandemic, given the new and unprecedented challenges involving viral exposure, personal protective equipment (PPE) and well-being.

DESIGN

Prospective cross-sectional survey study.

SETTING

Online international survey. Single-best, open box and Hospital Anxiety and Depression Scale (HADS) questions.

PARTICIPANTS

The survey was sent to 35 509 HCPs in 124 countries and was open from 7 to 21 May 2020. 2237/3237 (69.1%) HCPs from 115 countries who consented to participate completed the survey. 1058 (47.3%) completed the HADS.

PRIMARY OUTCOME MEASURES

Overall prevalence of SARS-CoV-2, depression and anxiety among HCPs in relation to country and PPE availability.

ANALYSES

Univariate analyses were used to investigate associations without generating erroneous causal conclusions.

RESULTS

Confirmed/suspected SARS-CoV-2 prevalence was 13.0%. PPE provision concerns were raised by 74.1% of participants; highest among trainees/resident physicians (83.9%) and among HCPs in Spain (89.7%). Most participants worked in self-perceived high-risk areas with SARS-CoV-2 (67.5%-87.0%), with proportionately more trainees interacting with suspected/confirmed infected patients (57.1% vs 24.2%-40.6%) and sonographers seeing more patients who did not wear a mask (33.3% vs 13.9%-7.9%). The most frequent PPE combination used was gloves and a surgical mask (22.3%). UK and US respondents reported spending less time self-isolating (8.8 days) and lower satisfaction with their national pandemic response (37.0%-43.0%). 19.8% and 8.8% of respondents met the criteria for moderate to severe anxiety and depression, respectively.

CONCLUSIONS

Reported prevalence of SARS-CoV-2 in HCPs is consistent with literature findings. Most respondents used gloves and a surgical mask, with a greater SARS-CoV-2 prevalence compared with those using 'full' PPE. HCPs with the least agency (trainees and sonographers) were not only more likely to see high-risk patients but also less likely to be protected. A fifth of respondents reported moderate to severe anxiety.

Rapid introduction of virtual consultation in a hospital-based Consultant-led Antenatal Clinic to minimise exposure of pregnant women to COVID-19

The COVID-19 global pandemic dictated rapid change to outpatient services within our London-based maternity hospital. Coupled with long waiting times in the Consultant-led Antenatal clinic, we aimed to reduce hospital footfall and unnecessary contact with a clinically vulnerable patient population by reducing face-to-face consultations. Numerous specialties have already successfully implemented safe and effective teleconferencing, allowing remote review while reducing the risks posed by face-to-face contact. A target to see at least 15% of women remotely was set to reduce footfall in the Consultant-led Antenatal Clinic. We aimed to reduce face-to-face waiting times to a mean of 30 min. In March 2020, clinics were prevetted by the clinic consultant to carefully select appropriate women suitable for video or telephone consultations. Clinic templates were changed, increasing appointment times by 5–25 min each. ‘AccuRx’ software was tested and used to communicate appointment details and conduct the consultation. In-person waiting times in the clinic and number of virtual consultations over a 3-month period was recorded, along with qualitative feedback from service users and staff through surveys and departmental meetings. Mean waiting times were reduced by 33% from 45–30 min and multiple service-user benefits were noted, including partner involvement, convenience of waiting for appointments at home and removing requirement for childcare. However, limitations of internet connectivity, need for time to prevet clinics and lack of a robust administration system to inform women of their appointment type were highlighted. Further work is required in these areas to ensure sustainability and improvement of this process for the future.

A moving liver phantom in an anthropomorphic thorax for SPECT MP imaging

Cranio-caudal respiratory motion and liver activity cause a variety of complex myocardial perfusion (MP) artifacts, especially in the inferior myocardial wall, that may also mask cardiac defects. To assess and characterise such artifacts, an anthropomorphic thorax with moving thoracic phantoms can be utilised in SPECT MP imaging. In this study, a liver phantom was developed and anatomically added into an anthropomorphic phantom that also encloses an ECG beating cardiac phantom and breathing lungs’ phantom. A cranio-caudal respiratory motion was also developed for the liver phantom and it was synchronised with the corresponding ones of the other thoracic phantoms. This continuous motion was further divided into isochronous dynamic respiratory phases, from end-exhalation to end-inspiration, to perform SPECT acquisitions in different respiratory phases. The new motions’ parameters and settings were measured by mechanical means and also validated in a clinical environment by acquiring CT images and by using two imaging software packages. To demonstrate the new imaging capabilities of the phantom assembly, SPECT/CT MP acquisitions were performed and compared to previous phantom and patients studies. All thoracic phantoms can precisely perform physiological motions within the anthropomorphic thorax. The new capabilities of the phantom assembly allow to perform SPECT/CT MP acquisitions for different cardiac-liver activity ratios and cardiac-liver proximities in supine and, for first time, in prone position. Thus, MP artifacts can be characterised and motion correction can be performed due to these new capabilities. The impact of artifacts and motion correction on defect detection can be also investigated.

Changes in Circulating Kisspeptin Levels During Each Trimester in Women With Antenatal Complications

CONTEXT

Antenatal complications such as hypertensive disorders of pregnancy (HDP), fetal growth restriction (FGR), gestational diabetes (GDM), and preterm birth (PTB) are associated with placental dysfunction. Kisspeptin has emerged as a putative marker of placental function, but limited data exist describing circulating kisspeptin levels across all 3 trimesters in women with antenatal complications.

OBJECTIVE

We aimed to assess whether kisspeptin levels are altered in women with antenatal complications.

METHODS

Women with antenatal complications (n = 105) and those with uncomplicated pregnancies (n = 265) underwent serial ultrasound scans and blood sampling at the Early Pregnancy Assessment Unit at Hammersmith Hospital, UK, at least once during each trimester (March 2014 to March 2017). The women with antenatal complications (HDP [n = 32], FGR [n = 17], GDM [n = 35], PTB [n = 11], and multiple complications [n=10]) provided 373 blood samples and the controls provided 930 samples. Differences in circulating kisspeptin levels were assessed.

RESULTS

Third-trimester kisspeptin levels were higher than controls in HDP but lower in FGR. The odds of HDP adjusted for gestational age, maternal age, ethnicity, BMI, smoking, and parity were increased by 30% (95% CI, 16%-47%; P < 0.0001), and of FGR were reduced by 28% (95% CI, 4-46%; P = 0.025), for every 1 nmol/L increase in plasma kisspeptin. Multiple of gestation-specific median values of kisspeptin were higher in pregnancies affected by PTB (P = 0.014) and lower in those with GDM (P = 0.020), but not significantly on multivariable analysis.

CONCLUSION

We delineate changes in circulating kisspeptin levels at different trimesters and evaluate the potential of kisspeptin as a biomarker for antenatal complications.

Ultrasound characteristics, serum biochemistry and outcome of ectopic pregnancies presenting during COVID-19 pandemic

OBJECTIVE

To describe and compare the characteristics of ectopic pregnancies (EPs) in the year prior to vs during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

This was a retrospective analysis of women diagnosed with an EP on transvaginal sonography conducted at a center in London, UK, providing early-pregnancy assessment, between 1 January 2019 and 31 December 2020. Women were identified via the Astraia ultrasound reporting system using coded and non-coded outcomes of EP or pregnancy outside the uterine cavity. Data related to predefined outcomes were collected using Astraia and Cerner electronic reporting systems. Main outcome measures included clinical, ultrasound and biochemical features of EP, in addition to reported complications and management.

RESULTS

There were 22 683 consultations over the 2-year period. Following consultation, a similar number and proportion of EPs were diagnosed in 2019 (141/12 657 (1%)) and 2020 (134/10 026 (1%)). Both cohorts were comparable in age, ethnicity, weight and method of conception. Gestational age at the first transvaginal sonography scan and at diagnosis were similar, and no difference in location, size or morphology of EP was found between the two cohorts. Serum human chorionic gonadotropin (hCG) levels at the time of EP diagnosis were higher in 2020 than in 2019 (1005 IU/L vs 665 IU/L; P = 0.03). The proportions of women according to type of final EP management were similar, but the rate of failed first-line management was higher during vs before the pandemic (16% vs 6%; P = 0.01). The rates of blood detected in the pelvis (hemoperitoneum) on ultrasound (23% vs 26%; P = 0.58) and of ruptured EP confirmed surgically (9% vs 3%; P = 0.07) were similar in 2019 vs 2020.

CONCLUSIONS

No difference was observed in the location, size, morphology or gestational age at the first ultrasound examination or at diagnosis of EP between women diagnosed before vs during the COVID-19 pandemic. Complication rates and final management strategy were also unchanged. However, hCG levels and the failure rate of first-line conservative management measures were higher during the pandemic. Our findings suggest that women continued to access appropriate care for EP during the COVID-19 pandemic, with no evidence of diagnostic delay or an increase in adverse outcome in our population. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Evaluating cut-off levels for progesterone, β human chorionic gonadotropin and β human chorionic gonadotropin ratio to exclude pregnancy viability in women with a pregnancy of unknown location: A prospective multicenter cohort study

INTRODUCTION

There is no global agreement on how to best determine pregnancy of unknown location viability and location using biomarkers. Measurements of progesterone and β human chorionic gonadotropin (βhCG) are still used in clinical practice to exclude the possibility of a viable intrauterine pregnancy (VIUP). We evaluate the predictive value of progesterone, βhCG, and βhCG ratio cut-off levels to exclude a VIUP in women with a pregnancy of unknown location.

MATERIAL AND METHODS

This was a secondary analysis of prospective multicenter study data of consecutive women with a pregnancy of unknown location between January 2015 and 2017 collected from dedicated early pregnancy assessment units of eight hospitals. Single progesterone and serial βhCG measurements were taken. Women were followed up until final pregnancy outcome between 11 and 14 weeks of gestation was confirmed using transvaginal ultrasonography: (1) VIUP, (2) non-viable intrauterine pregnancy or failed pregnancy of unknown location, and (3) ectopic pregnancy or persisting pregnancy of unknown location. The predictive value of cut-off levels for ruling out VIUP were evaluated across a range of values likely to be encountered clinically for progesterone, βhCG, and βhCG ratio.

RESULTS

Data from 2507 of 3272 (76.6%) women were suitable for analysis. All had data for βhCG levels, 2248 (89.7%) had progesterone levels, and 1809 (72.2%) had βhCG ratio. The likelihood of viability falls with the progesterone level. Although the median progesterone level associated with viability was 59 nmol/L, VIUP were identified with levels as low as 5 nmol/L. No single βhCG cut-off reliably ruled out the presence of viability with certainty, even when the level was more than 3000 IU/L, there were 39/358 (11%) women who had a VIUP. The probability of viability decreases with the βhCG ratio. Although the median βhCG ratio associated with viability was 2.26, VIUP were identified with ratios as low as 1.02. A progesterone level below 2 nmol/L and βhCG ratio below 0.87 were unlikely to be associated with viability but were not definitive when considering multiple imputation.

CONCLUSIONS

Cut-off levels for βhCG, βhCG ratio, and progesterone are not safe to be used clinically to exclude viability in early pregnancy. Although βhCG ratio and progesterone have slightly better performance in comparison, single βhCG used in this manner is highly unreliable.

Contemporary experience of polyhydramnios: A single-centre experience

Introduction

Polyhydramnios is common; the majority of cases are idiopathic, but maybe associated with fetal abnormality. Literature suggests the volume of amniotic fluid discriminates idiopathic from pathological polyhydramnios but is not unanimous. We assessed fetal anomaly incidence amongst women with polyhydramnios and the role of discriminatory variables in identifying pathological cases.

Methods

Retrospective observational cohort study at an inner‐city London fetal medicine centre. Records for patients referred and/or diagnosed with polyhydramnios were reviewed as well as maternal/fetal demographics, amongst singleton pregnancies using the Astraia™ database from January 2015–2016. Estimated fetal weight was calculated using the Hadlock model (biometry undertaken at diagnosis). Student's t‐test/one‐way ANOVA compared means; chi‐squared tests compared proportions.

Results

120 cases were identified. 36 (30%) had fetal abnormality. There was no difference in AFI between fetuses with an abnormality and without (26.7 vs 25.2 cm, P = 0.22). AFI was normalised for weight (AFI (cm)/estimated fetal weight (kg)): AFI/kg was significantly different between cases with fetal abnormality and without (24.4 vs 16.7 cm/kg, P < 0.001) – incidence of abnormality increased with increasing AFI/kg (P = 0.007). Early gestational diagnosis was associated with higher rates of anomaly (P = 0.004). Differences in AFI/kg between those with and without abnormality were not significant when adjusted for gestation. AFI was significantly higher in cases of abnormality diagnosed at later gestation (P = 0.005).

Conclusion

Excess volume of amniotic fluid alone does not denote abnormality. Earlier gestations and higher AFI/kg corresponded with significantly increased rates of anomaly. However, the latter is a result of confounding by gestation, which is closely correlated with fetal weight.

Performance of plasma kisspeptin as a biomarker for miscarriage improves with gestational age during the first trimester

OBJECTIVE

To compare the performance of kisspeptin and beta human chorionic gonadotropin (βhCG), both alone and in combination, as biomarkers for miscarriage throughout the first trimester.

DESIGN

Prospective, nested case-control study.

SETTING

Tertiary Centre, Queen Charlotte Hospital, London, United Kingdom.

PATIENT(S)

Adult women who had miscarriages (n = 95, 173 samples) and women with healthy pregnancies (n = 265, 557 samples).

INTERVENTION(S)

The participants underwent serial ultrasound scans and blood sampling for measurement of plasma kisspeptin and βhCG levels during the first trimester.

MAIN OUTCOME MEASURE(S)

The ability of plasma kisspeptin and βhCG levels to distinguish pregnancies complicated by miscarriage from healthy pregnancies unaffected by miscarriage.

RESULT(S)

Gestation-adjusted levels of circulating kisspeptin and βhCG were lower in samples from women with miscarriages than in women with healthy pregnancies by 79% and 70%, respectively. The area under the receiver-operating characteristic curve for identifying miscarriage during the first trimester was 0.874 (95% confidence interval [CI] 0.844-0.904) for kisspeptin, 0.859 (95% CI 0.820-0.899) for βhCG, and 0.916 (95% CI 0.886-0.946) for the sum of the two markers. The performance of kisspeptin in identifying miscarriage improved with increasing length of gestation, whereas that of βhCG worsened. A decision matrix incorporating kisspeptin, βhCG, and gestational age had 83% to 87% accuracy for the prediction of miscarriage.

CONCLUSION(S)

Plasma kisspeptin is a promising biomarker for miscarriage and provides additional value to βhCG alone, especially during later gestational weeks of the first trimester.

External validation of models to predict the outcome of pregnancies of unknown location: a multicentre cohort study

Objective

To validate externally five approaches to predict ectopic pregnancy (EP) in pregnancies of unknown location (PUL): the M6P and M6NP risk models, the two‐step triage strategy (2ST, which incorporates M6P), the M4 risk model, and beta human chorionic gonadotropin ratio cut‐offs (BhCG‐RC).

Design

Secondary analysis of a prospective cohort study.

Setting

Eight UK early pregnancy assessment units.

Population

Women presenting with a PUL and BhCG >25 IU/l.

Methods

Women were managed using the 2ST protocol: PUL were classified as low risk of EP if presenting progesterone ≤2 nmol/l; the remaining cases returned 2 days later for triage based on M6P. EP risk ≥5% was used to classify PUL as high risk. Missing values were imputed, and predictions for the five approaches were calculated post hoc. We meta‐analysed centre‐specific results.

Main outcome measures

Discrimination, calibration and clinical utility (decision curve analysis) for predicting EP.

Results

Of 2899 eligible women, the primary analysis excluded 297 (10%) women who were lost to follow up. The area under the ROC curve for EP was 0.89 (95% CI 0.86–0.91) for M6P, 0.88 (0.86–0.90) for 2ST, 0.86 (0.83–0.88) for M6NP and 0.82 (0.78–0.85) for M4. Sensitivities for EP were 96% (M6P), 94% (2ST), 92% (N6NP), 80% (M4) and 58% (BhCG‐RC); false‐positive rates were 35%, 33%, 39%, 24% and 13%. M6P and 2ST had the best clinical utility and good overall calibration, with modest variability between centres.

Conclusions

2ST and M6P performed best for prediction and triage in PUL.

Tweetable abstract

The M6 model, as part of a two‐step triage strategy, is the best approach to characterise and triage PULs.

The M6 model, as part of a two‐step triage strategy, is the best approach to characterise and triage PULs.

Triaging women with pregnancy of unknown location using two-step protocol including M6 model: clinical implementation study

OBJECTIVE

The M6 risk-prediction model was published as part of a two-step protocol using an initial progesterone level of ≤ 2 nmol/L to identify probable failing pregnancies (Step 1) followed by the M6 model (Step 2). The M6 model has been shown to have good triage performance for stratifying women with a pregnancy of unknown location (PUL) as being at low or high risk of harboring an ectopic pregnancy (EP). This study validated the triage performance of the two-step protocol in clinical practice by evaluating the number of protocol-related adverse events and how effectively patients were triaged.

METHODS

This was a prospective multicenter interventional study of 3272 women with a PUL, carried out between January 2015 and January 2017 in four district general hospitals and four university teaching hospitals in the UK. The final pregnancy outcome was defined as: a failed PUL (FPUL), an intrauterine pregnancy (IUP) or an EP (including persistent PUL (PPUL)). FPUL and IUP were grouped as low-risk and EP/PPUL as high-risk PUL. Serum progesterone and human chorionic gonadotropin (hCG) levels were measured at presentation in all patients. If the initial progesterone level was ≤ 2 nmol/L, patients were discharged and were asked to have a follow-up urine pregnancy test in 2 weeks to confirm a negative result. If the progesterone level was > 2 nmol/L or a measurement had not been taken, hCG level was measured again at 48 h and results were entered into the M6 model. Patients were managed according to the outcome predicted by the protocol. Those classified as 'low risk, probable FPUL' were advised to perform a urine pregnancy test in 2 weeks and those classified as 'low risk, probable IUP' were invited for a scan a week later. When a woman with a PUL was classified as high risk (i.e. risk of EP ≥ 5%) she was reviewed clinically within 48 h. One center used a progesterone cut-off of ≤ 10 nmol/L and its data were analyzed separately. If the recommended management protocol was not adhered to, this was recorded as a protocol deviation and classified as: unscheduled visit for clinician reason, unscheduled visit for patient reason or incorrect timing of blood test or ultrasound scan. The classifications outlined in the UK Good Clinical Practice (GCP) guidelines were used to evaluate the incidence of adverse events. Data were analyzed using descriptive statistics.

RESULTS

Of the 3272 women with a PUL, 2625 were included in the final analysis (317 met the exclusion criteria or were lost to follow-up, while 330 were evaluated using a progesterone cut-off of ≤ 10 nmol/L). Initial progesterone results were available for 2392 (91.1%) patients. In Step 1, 407 (15.5%) patients were classified as low risk (progesterone ≤ 2 nmol/L), of whom seven (1.7%) were ultimately diagnosed with an EP. In 279 of the remaining 2218 women with a PUL, the M6 model was not applied owing to protocol deviation or because the outcome was already known (usually on the basis of an ultrasound scan) before a second hCG reading was taken; of these patients, 30 were diagnosed with an EP. In Step 2, 1038 women with a PUL were classified as low risk, of whom eight (0.8%) had a final outcome of EP. Of 901 women classified as high risk at Step 2, 275 (30.5%) had an EP. Therefore, 275/320 (85.9%) EPs were correctly classified as high risk. Overall, 1445/2625 PUL (55.0%) were classified as low risk, of which 15 (1.0%) were EP. None of these cases resulted in a ruptured EP or significant clinical harm. Sixty-two women participating in the study had an adverse event, but no woman had a serious adverse event as defined in the UK GCP guidelines.

CONCLUSIONS

This study has shown that the two-step protocol incorporating the M6 model effectively triaged the majority of women with a PUL as being at low risk of an EP, minimizing the follow-up required for these patients after just two visits. There were few misclassified EPs and none of these women came to significant clinical harm or suffered a serious adverse clinical event. The two-step protocol incorporating the M6 model is an effective and clinically safe way of rationalizing the management of women with a PUL. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Abdominal wall endometriosis in a region distant to the caesarean section scar

Abdominal wall endometriosis (AWE) is a rare entity presenting as a painful lump with a cyclical pattern, associated with previous caesarean section (CS). AWE is typically located at the site of the CS scar. The diagnosis is challenging in the rare instance when AWE presents at a location distant to the CS scar. A 37-year-old patient presented to a general surgeon with a 2-year history of left-sided, periumbilical pain exacerbated during her menstrual periods. A 3 cm firm and tender nodule was noted clinically. Intraoperatively, the nodule involved the rectus muscle and infiltrated the peritoneum. Histology confirmed endometriosis, and the patient recovered uneventfully. The rarity of this clinical entity and the fact that AWE mostly presents to non-gynaecologists make the diagnosis challenging prolonging its physical and psychological morbidity. Thorough history-taking with emphasis on the pattern of pain and a previous history of CS should raise suspicion of AWE.

Genetic Variants Predict Optimal Timing of Radiotherapy to Reduce Side-effects in Breast Cancer Patients

AIMS

Radiotherapy is an important treatment for many types of cancer, but a minority of patients suffer long-term side-effects of treatment. Multiple lines of evidence suggest a role for circadian rhythm in the development of radiotherapy late side-effects.

MATERIALS AND METHODS

We carried out a study to examine the effect of radiotherapy timing in two breast cancer patient cohorts. The retrospective LeND cohort comprised 535 patients scored for late effects using the Late Effects of Normal Tissue-Subjective Objective Management Analytical (LENT-SOMA) scale. Acute effects were assessed prospectively in 343 patients from the REQUITE study using the CTCAE v4 scales. Genotyping was carried out for candidate circadian rhythm variants.

RESULTS

In the LeND cohort, patients who had radiotherapy in the morning had a significantly increased incidence of late toxicity in univariate (P = 0.03) and multivariate analysis (P = 0.01). Acute effects in the REQUITE group were also significantly increased in univariate analysis after morning treatment (P = 0.03) but not on multivariate analysis. Increased late effects in the LeND group receiving morning radiotherapy were associated with carriage of the PER3 variable number tandem repeat 4/4 genotype (P = 6 × 10-3) and the NOCT rs131116075 AA genotype (P = 5 × 10-3).

CONCLUSION

Our results suggest that it may be possible to reduce toxicity associated with breast cancer radiotherapy by identifying gene variants that affect circadian rhythm and scheduling for appropriate morning or afternoon radiotherapy.

Coping Actions and Occupational Stress among School Teachers

A questionnaire was used to identify the relative frequency with which a sample of comprehensive school teachers used various actions to cope with occupational stress. The most frequently used coping actions reported were ‘try to keep things in perspective’, ‘try to avoid confrontations’ and ‘try to relax after work’. A principal components analysis of the coping actions revealed three factors which were labelled ‘express feelings and seek support’, ‘take considered actions’ and ‘think of other things’.

Germ cell damage and Leydig cell insufficiency in recipients of nonmyeloablative transplantation for haematological malignancies

Most bone marrow transplant recipients are infertile due to reversible or irreversible testicular failure. However, little is known about the gonadotoxic potential of the newly introduced nonmyeloablative transplants. We undertook a 24-month longitudinal study in a cohort of 32 recipients of nonmyeloablative transplantation to test whether the combined regimen of fludarabine, melphalan and CAMPATH-1H can induce damage to germ cell (GC) and Leydig cell (LC) compartments. Testicular function was assessed immediately prior to transplantation and at four time points post-transplant to compare hormonal levels before and after the procedure. Two other groups treated with BEAM- and TBI-related regimes were also included in the study group for comparative purposes. GC function was assessed by measuring basal serum follicle stimulating hormone (FSH). LC function was assessed by measuring basal luteinising hormone (LH) and testosterone (T) levels. LC reserve was assessed by measuring the T/LH ratio. As a group, patients who received a non myeloablative transplant sustained severe damage to the GC compartment, as evident from a substantial elevation in the FSH level post-transplant (12 IU/l vs 18.4 IU/l, P<0.001). Similar to the GC injury, patients as a group sustained significant damage to the LC compartment following the transplant (5.4 IU/l vs 9.6 IU/l, P<0.001). In general, patients had reduced LC reserve post-BMT, as evident from a diminished T/LH ratio (2.6 pretransplant vs 1.6 post-transplant P=0.05). Patients who received a nonmyeloablative transplant had a similar effect on the GC and LC compartments compared to those who had a BEAM autograft. On the other hand, patients who received a TBI-based transplant sustained more damage to their GC and LC compartments compared to those who received a nonmyeloblative transplant; however, this was not statistically significant (P=0.09). Our data suggest that this type of regimen is potentially gonadotoxic and consideration should be given to fertility counselling and testosterone replacement therapy post-transplant.

Courtship song genes and speciation in sand flies

Lutzomyia longipalpis (Lutz & Neiva, 1912) (Diptera: Psychodidae: Phlebotominae) is a vector of visceral leishmaniasis in the Americas and it might represent a complex of sibling species. Reproductive isolation between closely related species often involves differences in courtship behaviour. cacophony (cac) and period (per) are two Drosophila genes that control features of the "lovesong" males produce during courtship that has been implicated in the sexual isolation between closely related species. We are using gene fragments from L. longipalpis' homologues of these two genes to study the speciation process in this putative species complex.

Molecular Dissection of the 5' Region of no-on-transientA of Drosophila melanogaster Reveals cis-Regulation by Adjacent dGpi1 Sequences

The nonA gene of Drosophila melanogaster is important for normal vision, courtship song, and viability and lies approximately 350 bp downstream of the dGpi1 gene. Full rescue of nonA mutant phenotypes can be achieved by transformation with a genomic clone that carries approximately 2 kb of 5' regulatory material and that encodes most of the coding sequence of dGpi1. We have analyzed this 5' region by making a series of deleted fragments, fusing them to yeast GAL4 sequences, and driving UAS-nonA expression in a mutant nonA background. Regions that both silence and enhance developmental tissue-specific expression of nonA and that are necessary for generating optomotor visual responses are identified. Some of these overlap the dGpi1 sequences, revealing cis-regulation by neighboring gene sequences. The largest 5' fragment was unable to rescue the normal electroretinogram (ERG) consistently, and no rescue at all was observed for the courtship song phenotype. We suggest that sequences within the nonA introns that were missing in the UAS-nonA cDNA may carry enhancer elements for these two phenotypes. Finally, we speculate on the striking observation that some of the cis-regulatory regions of nonA appear to be embedded within the coding regions of dGpi1.

Pathology and clinical features of gastro-intestinal lymphoma in Saudi Arabia

The histopathology and clinical presentation of 19 cases of primary gastrointestinal lymphoma is described. Our patients are similar to others in the Middle East but have a lower incidence of diarrhoea and malabsorption. All revealed a widespread chronic inflammatory background. Four patients with primary gastric lymphoma had endoscopic biopsies from the duodenum; these biopsies were completely free from tumour but showed a moderate to severe diffuse lymphoplasmacytic infiltrate. Electron microscopy shows that tumour cells penetrate basement membranes and invade the epithelium which becomes thin and attenuated. Substances which inhibit lymphocyte tropism might be useful in preventing intestinal ulceration. The MALT concept has been found useful in classification of the tumours. Two patients with unusual mesenteric node histology are described and it is thought that the appearances may indicate a substantial capacity for differentiation in the group of tumours.

Function of the Y optic nerve fibres in the cat: do they contribute to acuity and ability to discriminate fast motion?

1. A controlled pressure block has been applied to the optic nerve of the cat, sufficient to bring about degeneration of the axons of the large (Y) nerve fibres caudal to the block site. This degeneration has been monitored by means of implanted electrodes in optic nerve and tract which have shown a loss of the short-latency (t1) response 4-6 days after the block, and also by histological examination of the optic nerve. 2. Cats with one optic nerve blocked in this way have been used in behavioural experiments, one or other eye being covered during the tests. Tested via the blocked nerve, all cats with loss of only Y fibres could perform certain tests: the visual placing reaction, the blink reflex, the pupillary (light) reflex and simple manoeuvres such as walking a plank and jumping from table to floor. 3. When acuity was tested by means of the Mitchell jumping apparatus, cats with loss of only Y fibres showed the same acuity using either eye. This was true also of one cat in which many X fibres had also degenerated, as evidenced by a 55% loss of the medium-latency (t2) response, but in another cat with 90% loss of the t2 response acuity was reduced to about half-normal. 4. Ability to discriminate fast motion was tested by a modification of the Mitchell apparatus. All cats were able to discriminate the motion of an 11.5 deg spot up to a velocity of 6260 deg/s, whether using their normal eye or their affected eye. However, the loss of the Y fibres reduced the ability to discriminate fast motion, so that for any given level of contrast the velocity which could be discriminated was about two-thirds of the velocity discriminated using the normal eye. The ability of the cat to discriminate fast motion seems to be similar to that of the human. 5. These results suggest that there is no sharp restriction of function between the Y and X systems but instead considerable overlap. However, each system possesses specialized features giving it superiority in certain conditions.

Selective degeneration of optic nerve fibres in the cat produced by a pressure block

Using a technique described previously, we have applied pressure to the optic nerve of a cat sufficient to cause conduction block of the t1 response (the response of the Y optic nerve fibres). A greater pressure, usually sufficient to cause a transient block of the t2 response (the response of the X fibres), leads to degeneration of the Y axons caudal to the block. This is demonstrated by the disappearance of the t1 response in this region after 4-5 days and by the presence in electron micrographs of degenerating large (Y) fibres. Some small fibres also show degeneration, but the medium (X) fibres are largely spared. The time course of loss of response in the Y fibres is similar whether the loss is due to a pressure block or to enucleation, suggesting that the pressure block as used by us causes a disruption of the axon. If the pressure is great enough to block part of the t2 response (X fibres) there is also a similarity in time course of loss of response to that following enucleation. Both for the enucleated and the pressure-blocked cat the t2 response fails about 1 day before the t1 response. This is in apparent disagreement with the morphological findings in the literature, confirmed here, indicating an earlier degeneration of the larger fibres. The post-synaptic response in the lateral geniculate nucleus to the t1 input (the r1 response) also fails about 1 day before the t1 response. In the visual cortex the loss of the r1 response reveals more clearly than is normally possible an r2 response, the response of the X optic radiation fibres. The response in the optic nerve or tract to a bright flash of light is dominated by the response of the Y fibres. When these are blocked the response is greatly reduced.