Pregnancy outcomes for women with pre-existing renal disease and the role of a dedicated joint maternal medicine and renal clinic: A retrospective cohort study

OBJECTIVE

To reaffirm the value of a joint obstetric and renal clinic on obstetric outcomes in patients with high-risk pregnancies due to chronic kidney disease (CKD).

METHODS

This was a retrospective cohort study of patients who attended the clinic between 2005 and December 2021. The hospital is a regional tertiary unit for renal medicine and a maternal medicine hub. The data included all women with pre-existing renal conditions who were cared for in a dedicated renal and obstetric clinic. Datasets were extracted from hospital notes, the renal database, clinical data and maternity electronic health records. The data analyzed included pre-existing renal conditions, biochemical parameters related to the renal condition, pregnancy outcomes included miscarriages, gestation, mode of delivery, postpartum hemorrhage (PPH), loss, birth weight and neonatal admission.

RESULTS

The results were as follows: Lupus nephritis: four term deliveries; three had pre-eclampsia; two PPH and two miscarriages. Four estimated glomerular filtration rates (eGFRs) returned to baseline levels within 12 months. With regard to IgA nephropathy there were five live births, four term deliveries, two pre-eclampsia (PE) and five cesarean sections (CS). All eGFRs returned to baseline within 12 months. With regard to patients with adult polycystic kidney disease (APKD), there were six live births, two had pre-eclampsia and there were five term vaginal deliveries.

CONCLUSION

Patients with lupus nephritis, APKD, and IgA demonstrated a higher incidence of adverse pregnancy outcomes as compared with our local pregnant population. Our findings reflect those of larger studies and support the role of combined renal/obstetric clinics. More research and larger scale studies are needed into specific CKD conditions and their outcomes.

Effect of high frequency repetitive transcranial magnetic stimulation (rTMS) on the balance and the white matter integrity in patients with relapsing-remitting multiple sclerosis: A long-term follow-up study

OBJECTIVES

Repetitive Transcranial Magnetic Stimulation (rTMS) is considered as a safe and non-invasive developing technique used as a therapeutic method for patients with Relapsing-Remitting Multiple Sclerosis (RRMS) who suffer from disturbances in gait and balance. The aim of our study is to evaluate the long-term effect of high frequency rTMS as a therapeutic option for truncal ataxia in RRMS patients and to assess its impact on the integrity of the white matter (WMI), measured in the form of anisotropy metrics using diffusion tensor imaging (DTI).

METHODS

The study was conducted in two phases: phase I; a randomized, single-blind, sham-controlled phase and phase II was a 12 months longitudinal open-label prospective phase. Phase I of the trial involved the randomization of 43 patients with RRMS and truncal ataxia to either real (n = 20) or sham (n = 19) rTMS (2 participants from each treatment group were excluded from the study; one developed a relapse before treatment, 2 declined to participate, and one did not show up). Phase II involved providing 12 actual treatments cycles to all patients; each cycle length is 4 weeks, repeated four times on a trimonthly basis, forming a total of 48 sessions. DTI was used for assessment of the WMI. All patients performed DTI 3 times: Imaging sessions were conducted at the screening visit, at the end of phase I, and after the last session in phase II for the first, second and third sessions respectively. A figure-of-8-shape coil, employing rTMS protocol and located over the cerebellum, was used. rTMS protocol is formed of 20 trains formed of 50 stimuli with 20 s apart (5 Hz of 80 % of resting Motor Threshold "MT"). The Berg Balance Scale (BBS), Time up and go (TUG) test, and 10-m walk test (10MWT) were first evaluated at the start of each cycle and just after the final rTMS session.

RESULTS

The genuine rTMS group's 10MWT, TUG, and BBS showed substantial improvement (p < 0.01), which is continued to be improved throughout the study Timeline, with a significant difference observed following the final rTMS session (P< 0.001). A longitudinal increase in FA was observed in both the Cerebello-Thalamo-Cortical (CTC) and Cortico-Ponto-Cerebellar (CPC) bilateral, as indicated by means of Fractional Anisotropy (FA) measures (p < 0.05).

CONCLUSION

In ataxic RRMS patients, high frequency rTMS over the cerebellum has a long-term beneficial impact on both balance and WMI.

Managing couples with recurrent miscarriage: A narrative review and practice recommendations

There is significant variation in practice when managing couples with recurrent miscarriage (RM), with guidelines differing on the definition of RM, recommended investigations, and treatment options. In the absence of evidence-based guidance, and following on from a paper by the authors-FIGO Good Practice Recommendations on the use of progesterone in the management of recurrent first-trimester miscarriage-this narrative review aims to propose a global holistic approach. We present graded recommendations based on best available evidence.

Association of ACE1 I/D polymorphism and susceptibility to COVID-19 in Egyptian children and adolescents

BACKGROUND

Given the sparse data on the renin-angiotensin system (RAS) and its biological effector molecules ACE1 and ACE2 in pediatric COVID-19 cases, we investigated whether the ACE1 insertion/deletion (I/D) polymorphism could be a genetic marker for susceptibility to COVID-19 in Egyptian children and adolescents.

METHODS

This was a case-control study included four hundred sixty patients diagnosed with COVID-19, and 460 well-matched healthy control children and adolescents. The I/D polymorphism (rs1799752) in the ACE1 gene was genotyped by polymerase chain reaction (PCR), meanwhile the ACE serum concentrations were assessed by ELISA.

RESULTS

The ACE1 D/D genotype and Deletion allele were significantly more represented in patients with COVID-19 compared to the control group (55% vs. 28%; OR = 2.4; [95% CI: 1.46-3.95]; for the DD genotype; P = 0.002) and (68% vs. 52.5%; OR: 1.93; [95% CI: 1.49-2.5] for the D allele; P = 0.032). The presence of ACE1 D/D genotype was an independent risk factor for severe COVID-19 among studied patients (adjusted OR: 2.6; [95% CI: 1.6-9.7]; P < 0.001.

CONCLUSIONS

The ACE1 insertion/deletion polymorphism may confer susceptibility to SARS-CoV-2 infection in Egyptian children and adolescents.

IMPACT

Recent studies suggested a crucial role of renin-angiotensin system and its biological effector molecules ACE1 and ACE2 in the pathogenesis and progression of COVID-19. To our knowledge, ours is the first study to investigate the association of ACE1 I/D polymorphism and susceptibility to COVID-19 in Caucasian children and adolescents. The presence of the ACE1 D/D genotype or ACE1 Deletion allele may confer susceptibility to SARS-CoV-2 infection and being associated with higher ACE serum levels; may constitute independent risk factors for severe COVID-19. The ACE1 I/D genotyping help design further clinical trials reconsidering RAS-pathway antagonists to achieve more efficient targeted therapies.

Vitamin D deficiency and vitamin D receptor FokI polymorphism as risk factors for COVID-19

BACKGROUND

Given the sparse data on vitamin D status in pediatric COVID-19, we investigated whether vitamin D deficiency could be a risk factor for susceptibility to COVID-19 in Egyptian children and adolescents. We also investigated whether vitamin D receptor (VDR) FokI polymorphism could be a genetic marker for COVID-19 susceptibility.

METHODS

One hundred and eighty patients diagnosed to have COVID-19 and 200 matched control children and adolescents were recruited. Patients were laboratory confirmed as SARS-CoV-2 positive by real-time RT-PCR. All participants were genotyped for VDR Fok1 polymorphism by RT-PCR. Vitamin D status was defined as sufficient for serum 25(OH) D at least 30 ng/mL, insufficient at 21-29 ng/mL, deficient at <20 ng/mL.

RESULTS

Ninety-four patients (52%) had low vitamin D levels with 74 (41%) being deficient and 20 (11%) had vitamin D insufficiency. Vitamin D deficiency was associated with 2.6-fold increased risk for COVID-19 (OR = 2.6; [95% CI 1.96-4.9]; P = 0.002. The FokI FF genotype was significantly more represented in patients compared to control group (OR = 4.05; [95% CI: 1.95-8.55]; P < 0.001).

CONCLUSIONS

Vitamin D deficiency and VDR Fok I polymorphism may constitute independent risk factors for susceptibility to COVID-19 in Egyptian children and adolescents.

IMPACT

Vitamin D deficiency could be a modifiable risk factor for COVID-19 in children and adolescents because of its immune-modulatory action. To our knowledge, ours is the first such study to investigate the VDR Fok I polymorphism in Caucasian children and adolescents with COVID-19. Vitamin D deficiency and the VDR Fok I polymorphism may constitute independent risk factors for susceptibility to COVID-19 in Egyptian children and adolescents. Clinical trials should be urgently conducted to test for causality and to evaluate the efficacy of vitamin D supplementation for prophylaxis and treatment of COVID-19 taking into account the VDR polymorphisms.

Thrombophilia screening in women with recurrent first trimester miscarriage: is it time to stop testing? - a cohort study and systematic review of the literature

OBJECTIVE

There are numerous studies reporting a disproportionally high prevalence of thrombophilia in women with a history of recurrent miscarriage (RM), which has led to overdiagnosis and treatment without an improvement in clinical outcomes. The objective of our study was to assess the prevalence of inherited and acquired thrombophilia in a large cohort of women with a history of early RM using internationally agreed diagnostic criteria and inclusion parameters and compare it to the meta-analysis results of existing literature.

METHODS

DESIGN: Retrospective cohort study and systematic review of literature.

SETTING

This is a retrospective cohort study set-up in two dedicated tertiary centres for women with RM in Southwest London and Surrey. We reviewed all the available literature related to causes of RMs. We ascertained the prevalence of thrombophilia in the study population and compared it with historical and published prevalence in the general population.

PARTICIPANTS

1155 women between 2012 and 2017. All patients had three or more first trimester miscarriages and a full thrombophilia screen.

RESULTS

The overall prevalence of thrombophilia in our study population is 9.2% (106/1155) with 8.1% (94/1155) of cases positive for inherited thrombophilia, which is similar to the general population; Factor V Leiden (4.9%; 57/1155) and prothrombin gene mutation (2.9%; 34/1155) were the most common inherited thrombophilias, while only 1% (12/1155) tested positive for acquired thrombophilia. Persistent positive lupus anticoagulant (LA) was found in 0.5% (6/1155) and persistent positive anticardiolipin (ACL) antibodies with a value ≥40 U/mL was found in 0.5% (6/1155) of patients. Tests for LA/ACL were performed a minimum of 12 weeks apart thus meeting the revised Sapporo criteria for a diagnosis of antiphospholipid syndrome.

CONCLUSION

The findings of our study demonstrate that the prevalence of inherited thrombophilia is similar in women with RM to that in the general population. Similarly, the prevalence of acquired thrombophilia, using the revised Sapporo criteria, in the cohort of RMs is similar to that in the general population. Therefore, we do not recommend investigation or treatment of inherited or acquired thrombophilia in women with RM.

PROSPERO REGISTRATION NUMBER

CRD42020223554.

Cytokine profile in Egyptian children and adolescents with COVID-19 pneumonia: A multicenter study

BACKGROUND

To date, the cytokine profile in children and adolescent with novel coronavirus disease 2019 (COVID-19) has not been reported.

OBJECTIVES

We investigated serum levels of a panel of key cytokines in children and adolescent with COVID-19 pneumonia with a primary focus on "cytokine storm" cytokines such as interleukin (IL)-1β, IL-6, IL-17, IL-2, IL-4, IL-10, interferon (IFN-γ), tumor necrosis factor (TNF)-α, and two chemokines interferon-inducible protein-10 (IP-10) and IL-8. We also studied whether these cytokines could be potential markers for illness severity in COVID-19 pneumonia.

METHODS

Ninety-two symptomatic patients aged less than 18 years with confirmed COVID-19 pneumonia and 100 well-matched healthy controls were included in this multi-center study. For all patients, the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in respiratory fluid specimens was detected by real-time reverse-transcriptase polymerase chain reaction. We measured serum concentrations of studied cytokines by using flow cytometry.

RESULTS

Patients with COVID-19 had significantly higher median IL-1β, IL-6, IL-8, IL-10, IL-17, TNF-α, and IP-10 serum levels than did control children (all p < 0.01). Patients with severe COVID-19 pneumonia had significantly higher median IL-1β, IL-6, and IP-10 serum levels as compared with those with moderate COVID-19 pneumonia; all p < 0.01. ROC analysis revealed that three of the studied markers (IL-6, IL-1β, and IP-10) could predict severe COVID-19 pneumonia cases with the largest AUC for IL-6 of 0.893 (95% confidence interval: 0.84-0.98; p < 0.01).

CONCLUSION

Our study shows that pediatric patients with COVID-19 pneumonia have markedly elevated serum IL-1β, IL-6, IL-8, IL-10, IL-17, TNF-α, and IP-10 levels at the initial phase of the illness indicating a cytokine storm following SARS-CoV-2 infection. Moreover, serum IL-6, IL-1β, and IP-10 concentrations were independent predictors for severe COVID-19 pneumonia.

CHA2DS2 -VASc score as a predictor for contrast-induced nephropathy in patients with acute coronary syndrome undergoing percutaneous coronary intervention

Background

Contrast induced nephropathy (CIN) is one of the most important complications of PCI, resulting in increased medical resources, longer hospital stay and higher mortality so it is important to detect early high risk patients for CIN and provide them with preventive measures. In recent years, several studies have demonstrated an association of CHA2DS2-VASc score with cardiovascular prognosis and adverse outcomes in different populations including heart failure, SCAD and ACS beyond the original AF field. The predictive value of the CHA2DS2-VASc score on CIN still remains unclear although all of the components of the CHA2DS2-VASc score are important risk factors for CIN. For this reason, the present study was designed to evaluate the predictive value of preprocedural CHA2DS2-VASc score on the development of CIN in patients with ACS who underwent PCI.

Objective

To assess the predictive value of the CHA2DS2-VASc Score for contrast induced nephropathy among acute coronary syndrome patients who underwent percutaneous coronary intervention.

Material and methods

This study is a prospective study conducted over 300 patients with myocardial infarction underwent primary coronary intervention. It took place from February 2020 till September 2020. We analyzed patient's demographic data, clinical data, laboratory data, angiographic data and CHADSVASC score and followed up patients daily for 72 hour after PCI for development of CIN then compared these data in CIN versus non CIN patients trying to find out which of these factors can predict occurrence of CIN and find CHADSVASC score cutoff value for prediction of CIN.

Results

CIN was developed in 89 patients. A significant relationship existed between CIN and female gender, DM, HTN, door to needle time, killip class above one, contrast volume (p&lt;0.000), previous intervention using contrast (p&lt;0.001), anemia (p&lt;0.014), duration of procedure (p&lt;0.074) and number of coronary vessels affected (p&lt;0.031). However, non-significant relationship existed between CIN and Stroke, TIA, previous thromboembolism (p&lt;0.446), ejection fraction (p&lt;0.155), culprit vessel (p&lt;0.317), TIMI grade (p&lt;0.278) and antiplatelet type (p&lt;0.934). Receiver operating characteristic curve analysis showed good predictive value of CHA2DS2-VASc score for CIN (area under the curve 0.801, sensitivity 69.66% and specificity 80.75%). Patients with a CHA2DS2-VASc score cutoff value ≥4 had a higher liability for CIN (p&lt;0.000).

Conclusion

CHA2DS2-VASc score is a simple bedside risk score for preprocedure CIN risk stratification among ACS patients who underwent primary PCI.

Funding Acknowledgement

Type of funding sources: None.

Identification of harmine and β-carboline analogs from a high-throughput screen of an approved drug collection; profiling as differential inhibitors of DYRK1A and monoamine oxidase A and for in vitro and in vivo anti-cancer studies

DYRK1A (dual-specificity tyrosine phosphorylation-regulated kinase 1a) is highly expressed in glioma, an aggressive brain tumor, and has been proposed as a therapeutic target for cancer. In the current study, we have used an optimized and validated time-resolved fluorescence energy transfer (TR-FRET)-based DYRK1A assay for high-throughput screening (HTS) in 384-well format. A small-scale screen of the FDA-approved Prestwick drug collection identified the β-carboline, harmine, and four related analogs as DYRK1A inhibitors. Hits were confirmed by dose response and in an orthogonal DYRK1A assay. Harmine's potential therapeutic use has been hampered by its off-target activity for monoamine oxidase A (MAO-A) which impacts multiple nervous system targets. Selectivity profiling of harmine and a broader collection of analogs allowed us to map some divergent SAR (structure-activity relationships) for the DYRK1A and MAO-A activities. The panel of harmine analogs had varying activities in vitro in glioblastoma (GBM) cell lines when tested for anti-proliferative effects using a high content imaging assay. In particular, of the identified analogs, harmol was found to have the best selectivity for DYRK1A over MAO-A and, when tested in a glioma tumor xenograft model, harmol demonstrated a better therapeutic window compared to harmine.

Recurrent miscarriage: evidence to accelerate action

Women who have had repeated miscarriages often have uncertainties about the cause, the likelihood of recurrence, the investigations they need, and the treatments that might help. Health-care policy makers and providers have uncertainties about the optimal ways to organise and provide care. For this Series paper, we have developed recommendations for practice from literature reviews, appraisal of guidelines, and a UK-wide consensus conference that was held in December, 2019. Caregivers should individualise care according to the clinical needs and preferences of women and their partners. We define a minimum set of investigations and treatments to be offered to couples who have had recurrent miscarriages, and urge health-care policy makers and providers to make them universally available. The essential investigations include measurements of lupus anticoagulant, anticardiolipin antibodies, thyroid function, and a transvaginal pelvic ultrasound scan. The key treatments to consider are first trimester progesterone administration, levothyroxine in women with subclinical hypothyroidism, and the combination of aspirin and heparin in women with antiphospholipid antibodies. Appropriate screening and care for mental health issues and future obstetric risks, particularly preterm birth, fetal growth restriction, and stillbirth, will need to be incorporated into the care pathway for couples with a history of recurrent miscarriage. We suggest health-care services structure care using a graded model in which women are offered online health-care advice and support, care in a nurse or midwifery-led clinic, and care in a medical consultant-led clinic, according to clinical needs.

Association of Plasminogen Activator Inhibitor 1 (PAI-1) 4G/5G Polymorphism and Susceptibility to SLE in Egyptian Children and Adolescents: A Multicenter Study

BACKGROUND

Plasminogen activator inhibitor-1 (PAI-1) is a key molecule residing at the nexus between thrombosis and inflammatory processes. Recently, PAI-1 and its gene expression have emerged as a potential candidate for autoimmune disorders such as SLE.

OBJECTIVE

To investigate whether the PAI-1 4G/5G polymorphism at position -675 could be a genetic marker for susceptibility to childhood-onset SLE and development of lupus nephritis among Egyptian children and adolescents.

METHODS

Three hundred fifty patients diagnosed with childhood-onset SLE and 350 well-matched healthy controls were included in this multi-center study. All subjects were genotyped for the PAI-1 promoter 4G/5G polymorphism at position -675 using PCR- restriction fragment length polymorphism (RFLP). Serum PAI-1 levels were measured by ELISA.

RESULTS

The PAI-1 (- 675) 4G/4G genotype was more represented in c-SLE patients, as compared to the control group (38% vs 23%; OR =2.7; [95% CI: 1.47-2.9]; P < 0.001). Patients carrying the PAI-1 4G/4G genotype or 4G allele were more likely to develop lupus nephritis (OR: 3.38; [95% CI: 1.9-5.9]; P <0.001, for the 4G/4G genotype and OR: 2.6; [95% CI: 1.85-3.67]; for the 4G allele; P < 0.01). The PAI-1 4G/4G genotype was associated with higher PAI-1 serum concentrations (mean; 86.6±22.7 ng/mL) as compared to those with a 4G/5G genotype (mean; 48.3±16.5 ng/mL) and the lowest for the 5G/5G genotype (mean; 34.7±11.4 ng/mL); P = 0.004.

CONCLUSION

The PAI-1 4G/5G polymorphism may confer susceptibility to childhood-onset SLE and development of lupus nephritis among Egyptian children and adolescents. Moreover, the PAI-1 4G/4G genotype and 4G allele were associated with higher PAI-1 serum levels and higher disease activity scores.

QRS Duration as a Predictor of Left Ventricular Outflow Tract Velocity Time Integral in Patient with Cardiac Resynchronization Therapy

Background

Cardiac resynchronization therapy (CRT) has a morbidity and mortality benefits in moderate to severe heart failure. It reduces mortality and hospitalization and improves cardiac function. It can be used according to the European guidelines in severely depressed left ventricular ejection fraction (i.e., ≤35%) and complete left bundle branch block. However, 30% of patients may show no benefit from CRT therapy. Therefore, prediction of CRT response seems to be an important subject for study in the current researches. We aimed to study the correlation between Surface ECG QRS complex duration (QRS) duration and cardiac output measured by ventricular outflow tract velocity time integral (LVOT VTI) as a predictor of response in patients with CRT implantation.

Methods

We studied 100 consecutive patients prospectively with biventricular pacing system. The patients were studied at the pacemaker follow-up clinic. Each patient was subjected to: Full medical history, general and local examination, a 12 lead electrocardiogram and QRS duration in ms was measured. All patients were subjected to a focused transthoracic echocardiographic examination in which a parasternal long axis view was obtained to measure the diameter of the LVOT diameter in mid-systole. The LVOT VTI was measured by pulsed-wave Doppler in the LVOT using a 2-mm sample volume positioned just proximal to the aortic valve in the apical five chamber view.

Results

We found a statistically significant difference between CRT responders and nonresponders as regards age, body surface area (BSA), time since CRT implantation and smoking status (P = 0.018, 0.039, 0.002, <0.001). There was negative significant correlation between QRS duration and LVOT VTI and stroke volume index. The optimal cut off values for optimal response to CRT using receiver operating characteristics curves were 130 ms for postimplant QRS duration and 17.1 cm for LVOT VTI. We also found a significant difference between responders and nonresponders as regard CO. It was higher in responders (5.97 vs. 3.34, P < 0.001).

Conclusion

CRT response is more in patients with lower BSA, and without previous history of ischemic heart disease or smoking. There is a significant negative correlation between QRS duration and LVOT VTI.

Sperm DNA fragmentation is a novel biomarker for early pregnancy loss

RESEARCH QUESTION

Spontaneous pregnancy loss affects 10-15% of couples, with 1-2% suffering recurrent pregnancy loss and 50% of miscarriages remaining unexplained. Male genomic integrity is essential for healthy offspring, meaning sperm DNA quality may be important in maintaining a pregnancy. Does sperm DNA fragmentation measured by alkaline Comet assay act as a biomarker for early pregnancy loss?

DESIGN

Sperm DNA fragmentation was measured by alkaline Comet test in 76 fertile donors and 217 men whose partners had recently experienced miscarriage. Couples were divided into five groups for analysis: one miscarriage after spontaneous conception; two or more miscarriages after spontaneous conception; one miscarriage after fertility treatment; two or more miscarriages after fertility treatment and biochemical pregnancy.

RESULTS

Receiver operator characteristic curve analysis was used to determine ability of the average Comet score (ACS), low Comet score (LCS) and high Comet score (HCS) to diagnose miscarriage and develop clinical thresholds comparing men whose partners have miscarried with men with recently proven fertility. Male partners of women who had miscarried had higher sperm DNA damage (ACS 33.32 ± 0.57%) than fertile men (ACS 14.87 ± 0.66%; P < 0.001). Average Comet score, HCS and LCS all have promise as being highly predictive of sporadic and recurrent miscarriage using clinical thresholds from comparisons with fertile men's spermatozoa: receiver operating characteristic curve AUC for ACS ≥26%, 0.965; LCS ≤70%, 0.969; HCS ≥2%, 0.883; P <0.0001.

CONCLUSIONS

Sperm DNA damage measured by the alkaline Comet has promise as a robust biomarker for sporadic and recurrent miscarriage after spontaneous or assisted conception, and may provide novel diagnoses and guidance for future fertility pathways.

Metformin use in obese mothers is associated with improved cardiovascular profile in the offspring

BACKGROUND

Maternal obesity increases the risk for pregnancy complications and adverse neonatal outcome and has been associated with long-lasting adverse effects in the offspring, including increased body fat mass, insulin resistance, and increased risk for premature cardiovascular disease. Lifestyle interventions in pregnancy have produced no or modest effects in the reduction of adverse pregnancy outcomes in obese mothers. The Metformin in Obese Pregnant Women trial was associated with reduced adverse pregnancy outcomes and had no effect on birthweight. However, the long-term implications of metformin on the health of offspring remain unknown.

OBJECTIVE

The purpose of this study was to assess whether prenatal exposure to metformin can improve the cardiovascular profile and body composition in the offspring of obese mothers.

STUDY DESIGN

In 151 children from the Metformin in Obese Pregnant Women trial, body composition, peripheral blood pressure, and arterial pulse wave velocity were measured. Central hemodynamics (central blood pressure and augmentation index) were estimated with the use of an oscillometric device. Left ventricular cardiac function and structure were assessed by echocardiography.

RESULTS

Children were 3.9±1.0 years old, and 77 of them had been exposed to metformin prenatally. There was no significant difference in peripheral blood pressure, arterial stiffness, and body composition apart from gluteal and tricep circumferences, which were lower in the metformin group (P<.05). The metformin group, compared with the placebo group, had lower central hemodynamics (mean adjusted decrease, -0.707 mm Hg for aortic systolic blood pressure, -1.65 mm Hg for aortic pulse pressure, and -2.68% for augmentation index; P<.05 for all) and lower left ventricular diastolic function (adjusted difference in left atrial area, -0.525 cm², in isovolumic relaxation time, -0.324 msec, and in pulmonary venous systolic wave, 2.97 cm/s; P<.05 for all). There were no significant differences in metabolic profile between the groups.

CONCLUSION

Children of obese mothers who were exposed prenatally to metformin, compared with those who were exposed to placebo, had lower central hemodynamic and cardiac diastolic indices. These results suggest that the administration of metformin in obese pregnant women potentially may have a beneficial cardiovascular effect for their offspring.

Abstract D010: Developing an inflammatory breast cancer campaign: Results from focus groups led by Komen scholars

Introduction: Breast cancer (BC) remains the second leading cause of cancer deaths amongst women worldwide. In the United States, African American and Latino women are disproportionately burdened by the incidence and mortality of BC compared with Caucasian women. Inflammatory breast cancer (IBC) is a rare and aggressive form of BC. African American women are more likely to be diagnosed with IBC and at earlier age compared to whites. IBC frequently lacks a breast lump and hence is difficult to detect. IBC is often diagnosed late at stage III or IV and has worse prognosis than non-IBC BC. Critically, awareness of IBC continues to lag education on other breast cancers. Lifesaving information and resources to reduce cancer risks are not widespread amongst minority populations. Community engagement is a valuable asset that enhances the traditional biomedical scientist’s knowledge in understanding the connection between biological and social factors affecting a particular disease, with the goal of addressing, and ultimately diminishing, BC health disparities. Methods: The purpose of the focus groups were to determine the best methods and messages for community outreach to raise awareness about IBC. To follow up on our initial listening session at the 4th Annual Women’s Health Awareness Day at NCCU, several focus groups were engaged, each with 10-12 participants from various gender, racial, and economic demographics, recruited from the Raleigh and Durham communities. Participants were provided informed consent forms and demographic surveys to complete. With guidance and training from the Komen mentoring team, trainees crafted a marketing plan and focus group session guide. Trainees served as session moderators and note-takers and developed summary reports which highlighted themes from the sessions which included the following topics: knowledge of IBC, best methods for sharing health information, types of messages to raise awareness and promote action, and perceived barriers to breast cancer screening. Results: Information gathered from the focus group sessions provides a unique perspective to strategize and develop marketing campaigns to bring awareness to the community and minority populations in the community. Many participants were unfamiliar with IBC, how it is diagnosed, and treatment options. To better raise awareness about IBC, participants recommended the use of various social media platforms, promoting more one-on-one education, patient self-advocacy sessions, and changing the perception of the presence of lumps as an indicator of BC. Conclusion: Cancer incidence and mortality overall are declining in all groups in the United States; however, minority groups continue to suffer with increased risk of developing or dying from BC. Furthermore, there is a significant need to raise awareness and understanding of IBC in diverse communities. Partnerships between the community and researchers will facilitate the development of relevant and accessible information about IBC.

Citation Format: Portia L Andrews, Alanna Burwell, Maria S Dixon, Hamzah Kharabsheh, Dana M Gant, Tia A Tate, Hassan Shehata, Jodie M Fleming, Kearston L Ingraham, Seronda A Robinson, Nadine J Barrett, Kevin P Williams. Developing an inflammatory breast cancer campaign: Results from focus groups led by Komen scholars [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D010.

Metformin in Pregnancy Study (MiPS): protocol for a systematic review with individual patient data meta-analysis

INTRODUCTION

Gestational diabetes mellitus (GDM) is a common disorder of pregnancy and contributes to adverse pregnancy outcomes. Metformin is often used for the prevention and management of GDM; however, its use in pregnancy continues to be debated. The Metformin in Pregnancy Study aims to use individual patient data (IPD) meta-analysis to clarify the efficacy and safety of metformin use in pregnancy and to identify relevant knowledge gaps.

METHODS AND ANALYSIS

MEDLINE, EMBASE and all Evidence-Based Medicine will be systematically searched for randomised controlled trials (RCT) testing the efficacy of metformin compared with placebo, usual care or other interventions in pregnant women. Two independent reviewers will assess eligibility using prespecified criteria and will conduct data extraction and quality appraisal of eligible studies. Authors of included trials will be contacted and asked to contribute IPD. Primary outcomes include maternal glycaemic parameters and GDM, as well as neonatal hypoglycaemia, anthropometry and gestational age at delivery. Other adverse maternal, birth and neonatal outcomes will be assessed as secondary outcomes. IPD from these RCTs will be harmonised and a two-step meta-analytic approach will be used to determine the efficacy and safety of metformin in pregnancy, with a priori adjustment for covariates and subgroups to examine effect moderators of treatment outcomes. Sensitivity analyses will assess heterogeneity, risk of bias and the impact of trials which have not provided IPD.

ETHICS AND DISSEMINATION

All IPD will be deidentified and studies contributing IPD will have ethical approval from their respective local ethics committees. This study will provide robust evidence regarding the efficacy and safety of metformin use in pregnancy, and may identify subgroups of patients who may benefit most from this treatment modality. Findings will be published in peer-reviewed journals and disseminated at scientific meetings, providing much needed evidence to inform clinical and public health actions in this area.

P1501 Huge lateral wall ventricular pseudoaneurysm complicating a silent myocardial infarction

Introduction

Mechanical complications of acute myocardial infarction (AMI) are mainly ventricular septal rupture (VSR), free wall rupture, and ischemic mitral regurgitation. If the patient survives the acute phase, negative remodeling starts to occur leading to aneurysm or pseudoaneurysm formation.

Case report

A 44-year-old male patient, smoker with a past medical history of hypertension, diabetes mellitus and no past cardiac history except for recurrent pericardiocentesis of hemorrhagic pericardial effusion in another hospital since 3 months with no available data, presented to our medical facility complaining of dyspnea grade III with no orthopnea or paroxysmal nocturnal dyspnea that started 4 months ago and progressed gradually with no history of any acute events. He was hemodynamically stable with no audible murmurs and clear chest auscultation. Transthoracic echocardiography (TTE) showed reduced left ventricular (LV) systolic function (ejection fraction 40%) with accidentally discovered large lateral wall ventricular pseudoaneurysm containing a large mural thrombus (Panels A and B) and a small pericardial effusion with no evidence of constriction or tamponade. Cardiac Computed tomography (CT) confirmed the presence of large ventricular pseudoaneurysm with mural thrombus lining the wall of the aneurysm (Panels C and D). Invasive coronary angiography (CA) revealed a total occlusion of the left circumflex artery (LCx) and non significant lesions in the remaining coronaries. The patient refused to have surgery and he was discharged on anti-ischemic, anti-failure measures and anti-coagulation with close follow-up.

Conclusion

Bedside echocardiography is still the mainstay procedure for diagnosis of mechanical complications following AMI and other imaging modalities such as cardiac CT and cardiac magnetic resonance (CMR) are new diagnostic tools for confirming the diagnosis and planning for further interventions. Although rare, mechanical complications of AMI should always be considered in every ischemic patient.

Abstract P1501 Figure. Echo and CT images

P1468 a rare cause of chest pain:sudden rupture of aortic valsalva sinus aneurysm

Introduction

Sinus of Valsalva aneurysms (SOVAs) occur when there is a congenital defect in the aortic media and incomplete fusion of distal bulbar septum (primitive bulbus cordis) and truncal ridges. These aneurysms usually rupture into the right side of the heart, with the right ventricle being the most common.

Case Presentation

A 32 year old male patient who presented to our facility with an attack of ulcerative colitis activity ,elevated inflammatory markers and thrombocytosis. During hospital stay, he developed sudden onset of retrosternal compressing chest pain. On examination he was afebrile with a blood pressure of 130/80 mm Hg and pulse rate 110 beats per minute. He had soft systolic and early diastolic murmurs with normal chest auscultation; there was no haemodynamic discrepancy between left and right sides or stigmata of endocarditis.

His ECG showed sinus rhythm with no ST segment changes, and chest x ray was normal. Full blood count revealed thrombocytosis & normochromic normocytic anemia , cardiac enzymes were normal, blood cultures were sterile.

A 2D transthoracic echocardiography (TTE) revealed dilated left ventricular dimensions , there is an aneurysm of the right sinus of Valsalva which is communicating with the right ventricle (RV)confirmed by color Doppler and negative contrast seen inside RV during bubble study.

3D TTE showed a small fistulous track between the right sinus and RV.

The patient refused surgical or percutaneous closure.

Conclusion

Congenital RSVAs account for 0.1–3.5% of congenital heart defects.It has a higher incidence in Asian versus Western populations with male to female ratio 3:1. SOVAs arise from the right sinus of Valsalva in 80–85% of these cases and from the noncoronary sinus in 5–15%. They rarely arise from the left sinus, as the left coronary cusp embryologically is not derived from bulbar septum. This is distinct from acquired SOVAs, which can occur in any of the sinuses Traditionally, surgical closure has been the mainstay of treatment for RSOVAs, with an operative mortality rate of &lt;5% and excellent long-term outcomes.

Abstract P1468 Figure. RSOVA

P1521 Prosthetic heart valve-related stroke: a single center experience

OnBehalf

YIG-CVR

Introduction

Thromboembolic events or bleeding are by far the most frequent complications of prosthetic heart valves. Cerebrovascular stroke is one of the major thromboembolic complications of anticoagulation-related issues of prosthetic heart valves.

Aim of the work

To determine the pattern and risk factors of acute stroke in patients with prosthetic heart valves.

Methods and Patients

A retrospective single-center analysis of the database registry of consecutive acute stroke patients with mitral or aortic heart valve prostheses admitted to a tertiary care stroke specialized center from 01/01/2012 to 01/12/2017.

All patients were examined by a certified neurologist and underwent a complete work-up evaluation (Computed Tomography or Magnetic Resonance Imaging, Carotid Doppler ultrasound examination, complete blood tests, and electrocardiogram) and a transthoracic echocardiography (TTE) examination as well as transesophageal echocardiography (TOE) if valve dysfunction or thrombosis were suspected.

Results

214 patients with mitral or aortic valve prostheses were admitted by acute stroke in the duration from 01/01/2012 to 01/12/2017 with a mean age of 44 ± 15 years, 132 were males (61.7%) and 178 patients had mechanical valves (83.2%). 135 patients had mitral prosthesis (63.1%) and ischemic stroke was encountered in 151 patients (70.6%).

Conclusion

In a single center experience, mechanical prosthesis at the mitral valve position was associated with higher incidence of ischemic stroke. Proper close follow-up of INR levels as well as the surgical shift to biological instead of mechanical valve should decrease significantly the incidence of prosthetic valve related strokes.

Baseline, clinical and other parameters Patients (n = 214) Age (years) 44 ± 15 Mechanical valve 178 (83.2%) Atrial Fibrillation 101 (47.2%) Rheumatic Heart Disease 175 (81.8%) Left ventricular ejection fraction (%) 54 ±13 Mitral Only 135 (63.1%) Aortic Only 51 (23.8%) Double Valve Prosthesis 28 (13.1%) Ischemic stroke 151 (70.6%) Hemorrhagic stroke 47 (22%) Both ischemic and hemorrhagic stroke 16 (7.4%) Data are represented as mean(±SD) or number (Percentage)

Abstract P1521 Figure. Valve sites

P1694 Prosthetic mitral valve infective endocarditis complicated by left ventricle to right atrial fistula

Case presentation

A 44 year old female patient presented to our hospital complaining of progressive exertional dyspnea and palpitations for 6 months, and high grade fever for 2 weeks. The patient had history of mitral valve replacement with mechanical prosthesis 16 years ago. The patient had no history of recent invasive procedures or dental interventions. General examination revealed an irregular pulse at rate of 100 beats per minute (bpm), blood pressure of 100/60 mmHg, temperature of 38.5 ͦ C and congested neck veins. Cardiac examination revealed an audible prosthetic mitral click with a harsh pansystolic murmur heard on the apex and left sternal border, and an accentuated P2 over the pulmonary area. Her resting electrocardiogram (ECG) showed atrial fibrillation with ventricular response of 110 bpm. Her laboratory investigations revealed normochromic normocytic anemia with Hemoglobin level of 8 g/dl (13-16), and leucocytosis with white blood cell count of 16.24 103 cell/ ul (4.00-11.00); as well as elevated C-reactive protein (CRP) level of 73 (0-3). Her international normalized ratio (INR) was 3 (1-1.3) on warfarin 5 mg.

Transthoracic echocardiography (TTE) revealed a dehiscent prosthetic mitral valve with severe paravalvular regurgitation, severe tricuspid valve regurgitation and pulmonary hypertension with predicted resting pulmonary artery systolic pressure of 60 mmHg. It also showed an abnormal jet passing from the LV into the RA above the tricuspid valve during systole, both right and left ventricular systolic functions were preserved. Subsequent 2D/3D transoesophageal echocardiography (TEE) confirmed the TTE findings with detection of LV-RA fistula with significant left to right shunt; it also visualized multiple vegetations attached to the mitral annulus at the site of the valve dehiscence.

The patient was diagnosed with prosthetic mitral valve infective endocarditis, empirical antibiotics were started and the patient was referred for another center for urgent surgery. Redo mitral valve replacement, tricuspid valve repair and closure of the defect were done; the patient developed complete heart block postoperatively and permanent pacemaker was inserted.

Conclusion

Infective endocarditis remains a major health problem with high mortality and severe complications. It is important to keep high index of suspicion in high risk patients for infective endocarditis as delayed diagnosis increases the risk of serious complications and mortality, and makes surgical intervention, if indicated, more demanding with increased incidence of perioperative complications.

Abstract P1694 Figure. TTE&TEE of prosthetic mitral IE

P1506 The correlation between left atrial volume index and cerebrovascular stroke

OnBehalf

YIG-CVR

Introduction

Increased left atrial (LA) size was associated with poor cardiovascular outcomes such as the development of heart failure, atrial fibrillation (AF), and stroke in the elderly.

Aim of the work

To determine the relation between left atrial volume index (LAVI) and the occurrence of ischemic cerebrovascular stroke (CVS) in patients with sinus rhythm.

Patients and Methods

A prospective analysis of the data of patients admitted to a tertiary care center. Left atrial volume index (LAVI) was measured in 1222 patients admitted to our center with first attack of acute ischemic cerebrovascular stroke (CVS) and the data was matched with 1222 patients admitted by diagnoses other than acute ischemic stroke.

Patients with valvular heart diseases, history of AF and with known cardio-embolic source of stroke as left ventricular thrombi or masses were excluded from both groups.

Results

The mean age was 61.1 ± 14.4 years in the CVS group and 61.5 ± 12.4 years in the control group, males were 806 (71.43%) in the CVS group and 852 (73.47%) in the control group. LAVI was 35 ± 10.3 ml/m2 in the CVS group while it was only 25.8 ± 6.4 ml/m2 in the control group which was statistically significant (P value= 0.002).

Conclusion

LAVI is a strong parameter that can be used to predict the occurrence of CVS in patients with sinus rhythm.

Total (n = 2444) Acute CVS (n = 1222) No CVS (n = 1222) P-value Age (years) 61.1 ± 14.4 61.5 ± 12.4 0.75 Sex (Males) 806 (66%) 852 (70%) 0.65 Diabetes 655 (53.6%) 603 (49.3%) 0.6 Hypertension 702 (57.5%) 675 (55.2%) 0.55 Smoking 599 (49%) 564 (46.2%) 0.71 Dyslipidemia 310 (25.4%) 299 (24.5%) 0.81 Mean BP (mmHg) 122 ± 15 119 ± 17 0.88 Heart rate (bpm) 82 ± 16 85 ± 18 0.76 Hemoglobin (g/dl) 12.3 ± 1.3 12.9 ± 1.7 0.61 Platelets (103/l) 255 ± 110 235 ± 95 0.35 INR 1.15 ± 0.11 1.09 ± 0.18 0.75 Ejection fraction (%) 55 ± 12 51 ± 11 0.41 LAVI (ml/m2) 35 ± 10.3 25.8 ± 6.4 0.002* Results are represented as number (%) or mean ± standard deviation, BP = Blood Pressure, INR = International Normalization Ratio, * significant P value &lt; 0.05

Abstract P1506 Figure. Comparison between both groups

P230 Pulmonary embolism due to hepatocellular carcinoma: A rare presentation

Introduction

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors and the second leading cause of cancer-related deaths. HCC is a highly progressive cancer with a high rate of metastasis. Intra-cardiac involvement with HCC is quite rare with a very poor prognosis. Acute pulmonary embolism is a very rare presentation of hepatocellular carcinoma (HCC) complicated with tumor thrombi into the inferior vena cava (IVC), right atrium (RA) and right ventricle (RV) with very poor reported prognosis.

Case presentation

A 72-years old hepatitis C virus (HCV) positive male patient for 20 years but he didn’t receive any treatment. He was admitted at our medical faculty with decompensated liver failure and resolved hepatic encephalopathy. He started complaining of acute onset of dyspnea. On clinical examination, he was tachypneic, tachycardic with thready pulse, distressed with deep icteric tinge. He had a massive ascites and bilateral lower limb pitting oedema. His electrocardiogram (ECG) showed sinus tachycardia. Urgent transthoracic echocardiography (TTE) revealed a large solid mass extending through the IVC to RA (Figure 1 Panel A) with another highly mobile cauliflower mass at the RV apex occupying the RV cavity, protruding into RA through TV and nearly obliterating RVOT into pulmonary artery. (Figure 1 Panel B, C, D). Due to patient’s frailty and hazards of contrast medium in an already impaired renal status of him, no further contrast study was performed. Only conservative and supportive measures were initiated for the management of his deteriorated general condition but unfortunately, he passed away shortly after.

Conclusion

Cardiac involvement in HCC rarely occurs and usually develops in advanced stages of HCC. The main mechanism of metastasis into the cardiac cavity is through a direct vascular extension of the tumor to the right side via hepatic vein and IVC. Acute pulmonary embolism in the setting of HCC is a quite rare manifestation of HCC that usually occur due to tumor thrombi in the IVC, RA and RV. The reported prognosis of HCC with intra-cardiac involvement is very poor, with a mean survival of 1 to 4 months at the time of diagnosis.

Abstract P230 Figure. TTE of HCC invading RVOT

Abstract A138: Profiling of harmine and select analogs as differential inhibitors of DYRK1A and monoamine oxidase A: Exploring the potential for anti-cancer efficacy and minimizing off-target activity

DYRK1A (dual-specificity tyrosine phosphorylation-regulated kinase 1a) phosphorylates a number of substrates on serine/threonine residues, including tau, amyloid precursor protein, DREAM, and GLI1. DYRK1A is expressed in both the adult and fetal brain, plays a key role in neurodevelopment and is critical for cell proliferation and differentiation in the brain. DYRK1A has been extensively studied as a drug target for Down syndrome (DS) and neurodegenerative diseases such as Alzheimer’s and Parkinson’s. DYRK1A has also been proposed as a therapeutic target for cancer, e.g., DYRK1A is highly expressed in glioma, an aggressive brain tumor that is resistant to chemo- and radio-therapy, and in a subset of glioblastoma (GBM) cell lines. Downregulation of DYRK1A in GBM cell lines decreases viability and reduces tumor growth in vivo. The β-carboline alkaloid harmine is one of the most potent and selective DYRK1A inhibitors and has been utilized as a specific tool compound to probe DYRK1A function in vitro and in vivo. We previously demonstrated that DYRK1A phosphorylates GLI1 at Ser-408 within a putative nuclear localization sequence and that this phosphorylation event is blocked by harmine. Harmine exhibits anti-cancer activity in vitro on a number of cancer cell lines, including glioma, breast, gastric and AML. However, harmine’s potential therapeutic use has been hampered by its potent “off-target” activity for monoamine oxidase A (MAO-A), impacting multiple nervous system targets. Harmine causes tremors in mice, thus limiting its in vivo dosing potential. In this current study, we have optimized and validated a TR-FRET based DYRK1A assay for high-throughput screening in 384-well format. A small-scale inhibitor screen of the FDA-approved Prestwick drug collection identified harmine and four of its analogs as DYRK1A inhibitors. Hits were confirmed by dose response and in an orthogonal DYRK1A assay. Selectivity profiling of harmine and a broader collection of analogs allowed us to map some divergent SAR (structure-activity relationships) for the DYRK1A and MAO-A activities. The panel of harmine analogs had varying activities in GBM cell lines when tested for anti-proliferative effects using a high content imaging assay. One of the analogs with reduced MAO-A activity relative to DYRK1A was tested in vivo in a glioma tumor model and demonstrated better characteristics/safety profile compared to harmine.

Citation Format: Hassan Shehata, Michael Tarpley, Helen O Oladapo, Dillon Strepay, Jose R Roques, Rob U Onyenwoke, David B Darr, Kevin P Williams. Profiling of harmine and select analogs as differential inhibitors of DYRK1A and monoamine oxidase A: Exploring the potential for anti-cancer efficacy and minimizing off-target activity [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference on Molecular Targets and Cancer Therapeutics; 2019 Oct 26-30; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2019;18(12 Suppl):Abstract nr A138. doi:10.1158/1535-7163.TARG-19-A138

Metformin in Pregnancy: Mechanisms and Clinical Applications

Metformin use in pregnancy is increasing worldwide as randomised controlled trial (RCT) evidence is emerging demonstrating its safety and efficacy. The Metformin in Gestational Diabetes (MiG) RCT changed practice in many countries demonstrating that metformin had similar pregnancy outcomes to insulin therapy with less maternal weight gain and a high degree of patient acceptability. A multicentre RCT is currently assessing the addition of metformin to insulin in pregnant women with type 2 diabetes. RCT evidence is also available for the use of metformin in pregnancy for women with Polycystic Ovarian Syndrome and for nondiabetic women with obesity. No evidence of an increase in congenital malformations or miscarriages has been observed even when metformin is started before pregnancy and continued to term. Body composition and metabolic outcomes at two, seven, and nine years have now been reported for the offspring of mothers treated in the MiG study. In this review, we will briefly discuss the action of metformin and then consider the evidence from the key clinical trials.

Abstract B47: Efficacy of GLI antagonists in triple-negative inflammatory breast cancer 2D and 3D models

Our objective was to investigate the differential effects of specific GLI1 antagonists in triple-negative inflammatory breast cancer 2D and 3D cell culture systems. Inflammatory breast cancer (IBC) accounts for 15% of all breast cancer deaths. IBC is a unique form of locally advanced breast cancer, an aggressive and highly invasive breast cancer having one of the worst clinical outcomes among breast cancers. African-American, American-Indian, and Arab-American women are disproportionately affected by IBC (1-3). Compared to non-IBC, IBC has a higher incidence of the triple-negative (TN) phenotype for which there are few treatment options. There are currently limited strategies for targeting IBC; thus, IBC patients continue to have worse survival outcomes than non-IBC breast cancer patients. GLI1 (glioma-associated oncogene homolog 1), the terminal effector of the hedgehog (Hh) pathway, has emerged as a potential therapeutic target for TN breast cancers including IBC (4). There is overwhelming evidence for GLI1 activation across many tumor types, including aggressive breast cancers, and its importance for tumor progression. Nuclear expression of GLI1 has been shown to be a strong predictor of poor prognosis in pancreatic cancer and brain gliomas and correlates with aggressiveness in basal-like breast cancer. In our studies, we utilized various automated phenotypic and functional assays (5) to examine the efficacy of GLI antagonists with varying mechanism of action for effects on IBC cell proliferation and growth in 2D and 3D cell culture systems. We are also assessing by high-throughput transcriptome sequencing (RNA-seq) gene expression differences in IBC cell lines after treatment with GLI antagonists. In both our 2D and 3D cell culture systems, TN-IBC cell lines were highly sensitive to two GLI antagonists, JK184 and GANT61. JK184 and GANT61 showed significant but differential effects on TN-IBC cell proliferation, colony formation, cell motility, and spheroid formation.

This study was supported in part by Department of Defense award W81WXH-13-1-0141, NIH award P20CA202924, Komen Graduate Training in Disparities Research award GTDR16377604, Developmental Funds from Duke School of Medicine and Duke Cancer Institute (as part of the P30CA014236 and Cancer and Environment Program supported by Mr and Mrs Fred and Alice Stanback P3917733).

References:

1. Anderson WF, Schairer C, Chen BE, et al. Epidemiology of inflammatory breast cancer (IBC). Breast Dis 2006;22(-1):9-23.

2. Woodward WA, Cristofanilli M. Inflammatory breast cancer. Semin Radiat Oncol 2009;19(4):256-65.

3. Hirko KA, Soliman AS, Banerjee M, et al. Characterizing inflammatory breast cancer among Arab Americans in the California, Detroit and New Jersey Surveillance, Epidemiology and End Results (SEER) registries (1988-2008). SpringerPlus. 2013;2(1).

4. Thomas Z, Gibson W, Sexton J, et al. Targeting GLI1 expression in human inflammatory breast cancer cells enhances apoptosis and attenuates migration. Br J Cancer. 2011;104:1575-86.

5. Williams KP, Allensworth JL, Ingram SM, et al. Quantitative high-throughput efficacy profiling of approved oncology drugs in inflammatory breast cancer models of acquired drug resistance and re-sensitization. Cancer Lett 2013;337:77-89.

Citation Format: Helen Oladapo, Xiaojia Ji, Hassan Shehata, Mike Tarpley, Lhoucine Chdid, David Lamson, Xuhui Bao, Scott Sauer, Gayathri R. Devi, Kevin P. Williams. Efficacy of GLI antagonists in triple-negative inflammatory breast cancer 2D and 3D models [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr B47.

Visceral fat mass as a novel risk factor for predicting gestational diabetes in obese pregnant women

Objective

To develop a model to predict gestational diabetes mellitus incorporating classical and a novel risk factor, visceral fat mass.

Methods

Three hundred two obese non-diabetic pregnant women underwent body composition analysis at booking by bioimpedance analysis. Of this cohort, 72 (24%) developed gestational diabetes mellitus. Principal component analysis was initially performed to identify possible clustering of the gestational diabetes mellitus and non-GDM groups. A machine learning algorithm was then applied to develop a GDM predictive model utilising random forest and decision tree modelling.

Results

The predictive model was trained on 227 samples and validated using an independent testing subset of 75 samples where the model achieved a validation prediction accuracy of 77.53%. According to the decision tree developed, visceral fat mass emerged as the most important variable in determining the risk of gestational diabetes mellitus.

Conclusions

We present a model incorporating visceral fat mass, which is a novel risk factor in predicting gestational diabetes mellitus in obese pregnant women.

Association between insulin resistance and preeclampsia in obese non-diabetic women receiving metformin

Objectives

To examine whether the reduced incidence of preeclampsia in non-diabetic obese pregnant women treated with metformin is mediated by changes in insulin resistance.

Methods

This was a secondary analysis of obese pregnant women in a randomised trial (MOP trial). Fasting plasma glucose and insulin were measured in 384 of the 400 women who participated in the MOP trial. Homeostasis model assessment of insulin resistance (HOMA-IR) was compared in the metformin and placebo groups and in those that developed preeclampsia versus those that did not develop preeclampsia.

Results

At 28 weeks, median HOMA-IR was significantly lower in the metformin group. Logistic regression analysis demonstrated that there was a significant contribution in the prediction of preeclampsia from maternal history of chronic hypertension and gestational weight gain, but not HOMA-IR either at randomisation (p = 0.514) or at 28 weeks (p = 0.643).

Conclusions

Reduced incidence of preeclampsia in non-diabetic obese pregnant women treated with metformin is unlikely to be due to changes in insulin resistance.

Metformin versus Placebo in Obese Pregnant Women without Diabetes Mellitus

BACKGROUND

Obesity is associated with an increased risk of adverse pregnancy outcomes. Lifestyle-intervention studies have not shown improved outcomes. Metformin improves insulin sensitivity and in pregnant patients with gestational diabetes it leads to less weight gain than occurs in those who do not take metformin.

METHODS

In this double-blind, placebo-controlled trial, we randomly assigned pregnant women without diabetes who had a body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) of more than 35 to receive metformin, at a dose of 3.0 g per day, or placebo (225 women in each group) from 12 to 18 weeks of gestation until delivery. The BMI was calculated at the time of study entry (12 to 18 weeks of gestation). The primary outcome was a reduction in the median neonatal birth-weight z score by 0.3 SD (equivalent to a 50% reduction, from 20% to 10%, in the incidence of large-for-gestational-age neonates). Secondary outcomes included maternal gestational weight gain and the incidence of gestational diabetes and of preeclampsia, as well as the incidence of adverse neonatal outcomes. Randomization was performed with the use of computer-generated random numbers. The analysis was performed according to the intention-to-treat principle.

RESULTS

A total of 50 women withdrew consent during the trial, which left 202 women in the metformin group and 198 in the placebo group. There was no significant between-group difference in the median neonatal birth-weight z score (0.05 in the metformin group [interquartile range, -0.71 to 0.92] and 0.17 in the placebo group [interquartile range, -0.62 to 0.89], P=0.66). The median maternal gestational weight gain was lower in the metformin group than in the placebo group (4.6 kg [interquartile range, 1.3 to 7.2] vs. 6.3 kg [interquartile range, 2.9 to 9.2], P<0.001), as was the incidence of preeclampsia (3.0% vs. 11.3%; odds ratio, 0.24; 95% confidence interval, 0.10 to 0.61; P=0.001). The incidence of side effects was higher in the metformin group than in the placebo group. There were no significant between-group differences in the incidence of gestational diabetes, large-for-gestational-age neonates, or adverse neonatal outcomes.

CONCLUSIONS

Among women without diabetes who had a BMI of more than 35, the antenatal administration of metformin reduced maternal weight gain but not neonatal birth weight. (Funded by the Fetal Medicine Foundation; ClinicalTrials.gov number, NCT01273584; EudraCT number, 2008-005892-83.).

The importance of visceral fat mass in obese pregnant women and relation with pregnancy outcomes

BACKGROUND

Maternal obesity is a well established risk factor for gestational diabetes but it is not known if the pattern of maternal fat distribution predicts adverse pregnancy outcomes.

METHODS

Body composition was assessed by bioimpedance using Inbody 720® in 302 consecutive obese pregnant women attending a weight management clinic. The relation of visceral fat mass and total percentage body fat with the development of gestational diabetes and perinatal outcomes was evaluated.

RESULTS

Women developing gestational diabetes (Group 1; n = 72) were older, had higher body mass indices and greater central obesity (waist:hip ratio, visceral fat mass) compared with those remaining normoglycaemic. Visceral fat mass, but not percentage body fat, correlated with fasting glucose in all patients (r = 0.2, p < 0.001) and particularly those in Group 1 (r = 0.35, p = 0.002). Visceral fat mass, but not percentage body fat, also correlated strongly with glycaemia, particularly in Group 1 (r = 0.47, p < 0.0001). Visceral fat mass also showed a weak but significant correlation with baby weight (r = 0.17, p = 0.01).

DISCUSSION

Central obesity, as assessed by early pregnancy waist:hip ratio and particularly by visceral fat mass, is a predictor of gestational diabetes in addition to classical risk factors and may help identify those obese patients at increased risk of complications.

Metformin effects on treatment satisfaction and quality of life in gestational diabetes

There is increasing interest in the use of metformin in gestational diabetes (GDM) but limited data on its impact on patients’ quality of life or treatment satisfaction. We assessed patients’ perspectives using the Audit of Diabetes-Dependent Quality of Life (ADDQoL) and Diabetes Treatment Satisfaction Questionnaire (DTSQ) in GDM women recruited postnatally and treated with metformin (n=68), insulin (n=32) or metformin and insulin (n=28) during pregnancy. Women with GDM taking either metformin or insulin demonstrated a higher quality of life (QoL) amongst each of the 19 life domains tested than women on the combination. Metformin treatment was associated with the least negative impact on QoL (−1.6) as compared with insulin and insulin + metformin groups (−1.7, -1.9) respectively. The Total Treatment Satisfaction (TTS) was highest in metformin treated patients (5.2) compared with insulin (4.7) or the combination (4.6). Metformin, compared with insulin either alone or in combination had the most favourable overall impact on patient reported quality of life and treatment satisfaction. These findings strengthen the case for considering metformin in GDM if lifestyle measures alone do not provide adequate glucose control.

Uric acid: is it time to give up routine testing in management of pre-eclampsia?

Ever since it was first linked with the pathophysiology of pre-eclampsia, uric acid has been a routine test requested by many care-givers managing pregnant women with hypertensive disease of pregnancy for almost 100 years. Existing evidence however suggests that it has no definitive role in prediction, diagnosis or management of pre-eclampsia. We argue against routine uric acid testing in pregnancies complicated by hypertension not only because it has become a fruitless academic exercise but also because ceasing its routine use will ensure cost-savings for the health services.

Pregnancy outcomes after metformin treatment for gestational diabetes: a case-control study

BACKGROUND

There is increasing evidence that metformin is safe and effective in the treatment of gestational diabetes (GDM), although it has not yet been widely accepted for routine practice. We compared pregnancy outcomes in women with gestational GDM treated with metformin or dietary measures alone.

METHODS

Women with GDM (324) not adequately controlled by diet received metformin according to protocol based on their home glucose results. Pregnancy outcomes in these women were compared with 175 GDM women treated with diet alone and matched for age and ethnicity.

RESULTS

The percentage of macrosomic babies (birth weight [BW] centile >90th centile) and small for gestational age (SGA) (BW <10th centile) in the metformin group was significantly reduced compared with the diet group (12.7% versus 20%; P < 0.05 [macrosomia]; 7.7% versus 14.3% [SGA] P < 0.05).

CONCLUSIONS

Metformin treatment had a favourable impact on the rates of macrosomia and SGA despite more severe glucose intolerance at baseline.

Pregnancy-associated atypical haemolytic uraemic syndrome in the postpartum period: a case report and review of the literature

Pregnancy has been reported to be a trigger in about 10% of all patients with atypical haemolytic uraemic syndrome (aHUS). However, in contrast to pregnancy-associated thrombotic thrombocytopaenic purpura, the presentation of pregnancy-associated aHUS remains ill defined and can therefore be difficult to diagnose and manage appropriately. Here we report a case of pregnancy-associated relapse of aHUS in a patient with a previous medical history of aHUS prior to pregnancy.

Metformin treatment for gestational diabetes

The prevalence of gestational diabetes mellitus (GDM) is rising as the pregnant population becomes older and more obese. This is concerning because GDM is associated with increased perinatal morbidity such as macrosomia and shoulder dystocia, and the need for instrumental delivery. In addition, the offspring of GDM women have increased long-term risks of obesity and type 2 diabetes. There is no doubt that treating women with GDM improves pregnancy outcomes. Conventionally this has been by diet and insulin. Although effective, insulin increases appetite leading to weight gain. It increases the risk of hypoglycaemia and needs to be given by injection. There is also a substantial cost in terms of time for teaching and educating patients. Metformin offers a logical alternative to insulin in GDM, by reducing insulin resistance. Recent trial evidence indicates it is safe and effective. We describe our experience with metformin in GDM and review the evidence.

Serum cystatin is not a marker of glomerular filtration rate in pregnancy

The role of cystatin C (Cys-C) as a marker of glomerular filtration rate (GFR) in pregnancy is undetermined. Measurements of Cys-C and creatinine (Cr) were taken at 14-17(+6), 18-23(+6), 27-31(+6) weeks' gestation, at delivery and 2-6 weeks postpartum in a prospective observational study of 27 women. There was no difference between Cys-C levels in early and late second trimester, but they were significantly higher in early third trimester (P < 0.001) than second trimester, despite no concurrent increase in Cr. Cys-C was also significantly higher at delivery than at all other times in pregnancy (P < 0.001) and fell to postpartum values higher than second trimester measurements (P < 0.01), but lower than delivery (P<0.001). In conclusion, changes in Cys-C may be influenced by pregnancy-related changes in glomerular filtration and therefore we would advise against their use as a marker of GFR in pregnancy.

Pregnancy outcomes in women with gestational diabetes treated with metformin or insulin: a case-control study

AIMS

To compare maternal and neonatal outcomes in women with gestational diabetes mellitus (GDM) treated with either metformin or insulin.

METHODS

One hundred and twenty-seven women with GDM not adequately controlled by dietary measures received metformin 500 mg twice daily initially. The dose was titrated to achieve target blood glucose values. Pregnancy outcomes in the 100 women who remained exclusively on metformin were compared with 100 women with GDM treated with insulin matched for age, weight and ethnicity.

RESULTS

There were no significant differences in baseline maternal risk factors. Women treated with insulin had significantly greater mean (sem) weight gain from enrolment to term (2.72 +/- 0.4 vs. 0.94 +/- 0.3 kg; P < 0.001). There was no difference between the metformin and insulin groups, respectively, comparing gestational hypertension (6 vs. 7%, P = 0.9), pre-eclampsia (9 vs. 2%, P = 0.06) induction of labour (26 vs. 24%, P = 0.87) or rate of Caesarean section (48 vs. 52%, P = 0.67). No perinatal loss occurred in either group. Neonatal morbidity was improved in the metformin group; prematurity (0 vs. 10%, P < 0.01), neonatal jaundice (8 vs. 30%, P < 0.01) and admission to neonatal unit (6 vs. 19%, P < 0.01). The incidence of macrosomia (birthweight centile > 90) was not significantly different [metformin (14%) vs. insulin (25%); P = 0.07].

CONCLUSIONS

Women with GDM treated with metformin and with similar baseline risk factors for adverse pregnancy outcomes had less weight gain and improved neonatal outcomes compared with those treated with insulin. Diabet. Med. 26, 798-802 (2009).