Prenatal vs postnatal diagnosis of 22q11.2 deletion syndrome: cardiac and noncardiac outcomes through 1 year of age

BACKGROUND

The 22q11.2 deletion syndrome is the most common microdeletion syndrome and is frequently associated with congenital heart disease. Prenatal diagnosis of 22q11.2 deletion syndrome is increasingly offered. It is unknown whether there is a clinical benefit to prenatal detection as compared with postnatal diagnosis.

OBJECTIVE

This study aimed to determine differences in perinatal and infant outcomes between patients with prenatal and postnatal diagnosis of 22q11.2 deletion syndrome.

STUDY DESIGN

This was a retrospective cohort study across multiple international centers (30 sites, 4 continents) from 2006 to 2019. Participants were fetuses, neonates, or infants with a genetic diagnosis of 22q11.2 deletion syndrome by 1 year of age with or without congenital heart disease; those with prenatal diagnosis or suspicion (suggestive ultrasound findings and/or high-risk cell-free fetal DNA screen for 22q11.2 deletion syndrome with postnatal confirmation) were compared with those with postnatal diagnosis. Perinatal management, cardiac and noncardiac morbidity, and mortality by 1 year were assessed. Outcomes were adjusted for presence of critical congenital heart disease, gestational age at birth, and site.

RESULTS

A total of 625 fetuses, neonates, or infants with 22q11.2 deletion syndrome (53.4% male) were included: 259 fetuses were prenatally diagnosed (156 [60.2%] were live-born) and 122 neonates were prenatally suspected with postnatal confirmation, whereas 244 infants were postnatally diagnosed. In the live-born cohort (n=522), 1-year mortality was 5.9%, which did not differ between groups but differed by the presence of critical congenital heart disease (hazard ratio, 4.18; 95% confidence interval, 1.56-11.18; P<.001) and gestational age at birth (hazard ratio, 0.78 per week; 95% confidence interval, 0.69-0.89; P<.001). Adjusting for critical congenital heart disease and gestational age at birth, the prenatal cohort was less likely to deliver at a local community hospital (5.1% vs 38.2%; odds ratio, 0.11; 95% confidence interval, 0.06-0.23; P<.001), experience neonatal cardiac decompensation (1.3% vs 5.0%; odds ratio, 0.11; 95% confidence interval, 0.03-0.49; P=.004), or have failure to thrive by 1 year (43.4% vs 50.3%; odds ratio, 0.58; 95% confidence interval, 0.36-0.91; P=.019).

CONCLUSION

Prenatal detection of 22q11.2 deletion syndrome was associated with improved delivery management and less cardiac and noncardiac morbidity, but not mortality, compared with postnatal detection.

Right ventricle in hypoplastic left heart syndrome exhibits altered hemodynamics in the human fetus

Hypoplastic left heart syndrome (HLHS) represents approximately 9% of all congenital heart defects and is one of the most complex, with the left side of the heart being generally underdeveloped. Numerous studies demonstrate that intracardiac fluid flow patterns in the embryonic and fetal circulation can impact cardiac structural formation and remodeling. This highlights the importance of quantifying the altered hemodynamic environment in congenital heart defects, like HLHS, relative to a normal heart as it relates to cardiac development. Therefore, to study human cardiovascular fetal flow, computational fluid dynamic simulations were performed using 4D patient-specific ultrasound scans in normal and HLHS hearts. In these simulations, we find that the HLHS right ventricle exhibits a greater cardiac output than normal; yet, hemodynamics are relatively similar between normal and HLHS right ventricles. Overall, this study provides detailed quantitative flow patterns for HLHS, which has the potential to guide future prevention and therapeutic interventions, while more immediately providing additional functional detail to cardiologists to aid in decision making.

Developing a comprehensive database with sensitive health information: A profile of people living with HIV in Newfoundland and Labrador, Canada

Introduction

Developing a comprehensive cohort of people living with HIV (PLHIV) to help improve healthcare has long been the vision of researchers, clinicians and decision makers. The development of this kind of database is challenging and requires strict adherence to privacy and confidentiality policies. We explored procedures, activities and events in database development.

Objectives

To understand processes of developing a database with sensitive health information in Newfoundland and Labrador (NL), and to investigate procedures and activities to develop the database within its environmental context.

Methods

A narrative case study was used to explain the challenges and procedures involved in developing a database for our population. The development of the PLHIV cohort in NL is provided as an example to demonstrate the complexity of the process. We linked three datasets that included patient-level data for PLHIV: 1. laboratory data; 2. HIV clinic data; 3. health administrative data, which allowed for the creation of a large database containing many variables describing the PLHIV cohort in the province.

Results

We developed a de-identified cohort of 251 PLHIV that contained 178 variables. Our case study showed database development is an iterative process. The main challenges were ensuring patient privacy and data confidentiality are not compromised and working with multi-custodian data. These challenges were addressed by establishing a data governance team.

Conclusions

It is important that policy be implemented to merge siloed data sources in order to provide researchers with accurate and complete data that is required to conduct sound and precise research with maximum benefits for treatment and policy-making to improve health outcomes.

Consequences of delivery at home in a woman without prenatal care

This is a case report of a 39-year-old multigravida woman without allopathic prenatal care who, after three previous caesarean sections, attempted to deliver her fourth child at home with the help of a direct entry midwife. During labour, fetal movement and fetal heart tones became undetectable, at which time the patient was referred by the midwife to the hospital. The patient was diagnosed with uterine rupture, bladder rupture and fetal demise; she was rushed to emergency surgery. The patient's lack of allopathic prenatal care, attempt of vaginal birth after three previous caesarean sections, coupled with her desire for delivery at home, led to her complicated course. The patient related that she was never made aware that attempting a home birth after three prior caesarean sections put her at increased risk for complications, and she was also unaware that midwives could have varying levels of training.

Haemophilia A carriers experience reduced health-related quality of life

INTRODUCTION

Haemophilia A is an X-linked recessive bleeding disorder that primarily affects males. Emerging data support evidence for increased bleeding in female haemophilia A carriers despite factor VIII activity within the normal range.

AIM

Data regarding the effect of increased bleeding on health-related quality of life (HR-QOL) in haemophilia A carriers is sparse. We tested the hypothesis that haemophilia A carriers have reduced HR-QOL related to bleeding symptoms.

METHODS

We conducted a cross-sectional study at Vanderbilt University. Case subjects were obligate or genetically verified haemophilia A carriers age 18-60 years. Control subjects were mothers of children with cancer who receive care at the Vanderbilt paediatric haematology-oncology clinic. Trained interviewers administered the Rand 36-Item Health Survey 1.0, a validated questionnaire evaluating eight health concepts that may affect HR-QOL, to each study participant. Mann-Whitney U-tests were used to compare median scores for the eight health domains between the case and control groups.

RESULT

Forty-two haemophilia A carriers and 36 control subjects were included in analyses. Haemophilia A carriers had significantly lower median scores for the domains of 'Pain' (73.75 vs. 90; P = 0.02) and 'General health' (75 vs. 85; P = 0.01) compared to control subjects.

CONCLUSION

Haemophilia A carriers in our study demonstrated significantly lower median scores on the Rand 36-item Health Survey 1.0 in the domains of 'Pain' and 'General Health' compared to women in the control group. Our findings highlight the need for further investigation of the effect of bleeding on HR-QOL in this population.

Tuberculosis report among injection drug users and their partners in Kazakhstan

OBJECTIVES

Tuberculosis (TB) is a major threat to global public health. Kazakhstan has the second highest percentage of multidrug-resistant tuberculosis (MDR-TB) cases among incident tuberculosis cases in the world (WHO 2013). A high burden of MDR-TB suggests TB prevention, control, and treatment programs are failing. This study provides an epidemiologic profile of TB among injection drug users (IDUs), a high-risk and chronically underserved population, in Kazakhstan.

STUDY DESIGN

Cross-sectional study.

METHODS

The authors studied the characteristics and risk environment of IDUs with self-reported previous active TB and their primary sexual partners in Almaty, Kazakhstan. 728 individuals (364 couples) participated in a couple-based study in 2009.

RESULTS

16.75% of participants reported at least one positive TB test (x-ray) in their lifetime. In a multivariable logistic regression adjusting for couple-based sampling, persons with positive TB test were significantly more likely to be older (odds ratio (OR) 7.26, 95% confidence interval (CI): 1.73, 30.43), male (OR 5.53, 95% CI: 2.74, 11.16), have a shorter duration of injection drug use (OR 0.17, 95% CI: 0.04, 0.65), have received high social support from their significant other (OR 2.13, 95% CI: 1.03, 4.40) and more likely (non-significantly) to have been incarcerated (OR 7.03, 95% CI: 0.64, 77.30).

CONCLUSIONS

Older men with a history of incarceration and recent injection drug use were more likely to have positive TB test in Kazakhstan. Social network support, while potentially positive for many aspects of population health, may increase risk of TB among IDUs in this context. Public health policies that target high-risk populations and their at-risk networks may be necessary to stem the rise of MDR-TB in Central Asia.

Screening histories and contact with physicians as determinants of cervical cancer risk in Montreal, Quebec

BACKGROUND

Cervical cancer (cca) is largely a preventable disease if women receive regular screening, which allows for the detection and treatment of preinvasive lesions before they become invasive. Having been inadequately screened is a common finding among women who develop cca. Our primary objective was to determine the Pap screening histories of women diagnosed with cca in Montreal, Quebec. Secondary objectives were to determine the characteristics of women at greatest risk of cca and to characterize the level of physician contact those women had before developing cca.

METHODS

The Invasive Cervical Cancer Study, a population-based case-control study, consisted of Greater Montreal residents diagnosed with histologically confirmed cca between 1998 and 2004. Respondents to the 2003 Canadian Community Health Survey and a sample of women without cca obtained from Quebec medical billing records served as controls.

RESULTS

During the period of interest, 568 women were diagnosed with cca. Immigrants and women speaking neither French nor English were at greatest risk of cca. Most of the women in the case group had been screened at least once during their lifetime (84.8%-90.4%), but they were less likely to have been screened within 3 years of diagnosis. Having received care from a family physician or a medical specialist other than a gynecologist within the 5 years before diagnosis was associated with a greater risk of cca development.

CONCLUSIONS

Our findings provide evidence of the need for an organized population-based screening program. They also underscore the need for provider education to prevent missed opportunities for cca screening when at-risk women seek medical attention.

A model to test how ticks and louping ill virus can be controlled by treating red grouse with acaricide

Ticks are the most important vectors of disease-causing pathogens in Europe. In the U.K., Ixodes ricinus L. (Ixodida: Ixodidae) transmits louping ill virus (LIV; Flaviviridae), which kills livestock and red grouse, Lagopus lagopus scoticus Lath. (Galliformes: Phasianidae), a valuable game bird. Tick burdens on grouse have been increasing. One novel method to reduce ticks and LIV in grouse may be acaricide treatment. Here, we use a mathematical model parameterized with empirical data to investigate how the acaricide treatment of grouse might theoretically control ticks and LIV in grouse. Assuming a situation in which ticks and LIV impact on the grouse population, the model predicts that grouse density will depend on deer density because deer maintain the tick population. In low deer densities, no acaricide treatment is predicted to be necessary because abundances of grouse will be high. However, at higher deer densities, the model predicts that grouse densities will increase only if high numbers of grouse are treated, and the efficacy of acaricide is high and lasts 20 weeks. The qualitative model predictions may help to guide decisions on whether to treat grouse or cull deer depending on deer densities and how many grouse can be treated. The model is discussed in terms of practical management implications.

The effect of deer management on the abundance of Ixodes ricinus in Scotland

The management of wildlife hosts for controlling parasites and disease has a history of mixed success. Deer can be important hosts for ticks, such as Ixodes ricinus, which is the primary vector of disease-causing zoonotic pathogens in Europe. Deer are generally managed by culling and fencing for forestry protection, habitat conservation, and commercial hunting, and in this study we test whether these deer management methods can be useful for controlling ticks, with implications for tick-borne pathogens. At different spatial scales and habitats we tested the hypotheses that tick abundance is reduced by (1) culling deer and (2) deer exclusion using fencing. We compared abundance indices of hosts and questing I. ricinus nymphs using a combination of small-scale fencing experiments on moorland, a large-scale natural experiment of fenced and unfenced pairs of forests, and cross-sectional surveys of forest and moorland areas with varying deer densities. As predicted, areas with fewer deer had fewer ticks, and fenced exclosures had dramatically fewer ticks in both large-scale forest and small-scale moorland plots. Fencing and reducing deer density were also associated with higher ground vegetation. The implications of these results on other hosts, pathogen prevalence, and disease risk are discussed. This study provides evidence of how traditional management methods of a keystone species can reduce a generalist parasite, with implications for disease risk mitigation.

Guideline on safer conception in fertile HIV-infected individuals and couples

Ninety years ago the isolation of insulin transformed the lives of people with type 1 diabetes. Now, models based on empirical data estimate that a 25-year-old person with HIV, when appropriately treated with antiretroviral therapy, can expect to enjoy a median survival of 35 years, remarkably similar to that for someone of the same age with type 1 diabetes. It is high time we normalised the lives of people living positively with HIV. This includes the basic human right to conceive and raise children. HIV-positive individuals may be in serodiscordant relationships or in seroconcordant relationships. As health care providers, it is our responsibility to ensure we understand the opportunities and risks of natural conception in these scenarios, so that we can help our patients to make informed decisions about their own lives. Most of all, it is our duty to make family planning in the setting of positive prevention as safe as we can. This includes informed decisions on contraception, adoption, fostering, conception and prevention of mother-to-child transmission. Some months ago a dedicated group of individuals, invited and sponsored by the Southern African HIV Clinicians Society, came together in Cape Town to devise guidance in this area, recognising that there are ideal strategies that may be outside the realm of the resource constraints of the public sector or health programmes in southern Africa. This guideline therefore attempts to provide a range of strategies for various resource settings. It is up to us, the providers, to familiarise ourselves with the merits/benefits and risks of each, and to then engage patients in meaningful discussions. All the above, however, is based on the premise and prerequisite that the subject of family planning is actively raised and frequently discussed in our patient encounters.Please find a link to the update of this guideline: http://sajhivmed.org.za/index.php/hivmed/article/view/399

Genital herpes testing among persons living with HIV

This cross-sectional survey explored the frequency of genital herpes testing among 110 people living with HIV (PLWH) and reported barriers and facilitators related to testing. Forty-four percent of the respondents had not been tested for genital herpes since receiving an HIV diagnosis, 34% had been tested, and 22% preferred not to say. Respondents' most frequently cited factors affecting a decision to not be tested were: (a) testing not being recommended by a provider, (b) not having herpes symptoms, and (c) not thinking they had herpes. Data from this study indicated that PLWH were not frequently tested for genital herpes; there was a limited understanding of the frequently subclinical nature of infection; and provider recommendations for testing, or lack thereof, affected testing decisions.

Neuroendocrine carcinoma of the uterine cervix: a single institution case review

OBJECTIVES

To investigate the clinicopathologic features and prognostic factors of neuroendocrine carcinoma of the cervix (NECC).

STUDY DESIGN

All patients with NECC diagnosed between January 1990 and December, 2007 identified from the tumor registry and gynecological oncology databases at McGill University Health Centre comprised this series.

RESULTS

Eleven cases were encountered. Four patients were FIGO Stage Ib1, one Stage Ib2, one Stage IIa, and the other five were advanced stages (III or IV). Ten patients had marked lymph vascular space invasion. Metastasis to the pelvic or paraortic nodes was observed in eight patients. Seven patients were treated by surgery followed by adjuvant chemoradiation, another two had chemoradiation and the other two only received palliative treatments. The median survival was 18 months. All three long-term survival patients were Stage Ib1 without lymph node involvement.

CONCLUSION

NECC is an aggressive tumor with poor prognosis, and only early stages are potentially curable.

PRECEDENT: A randomized phase II trial comparing EC145 and pegylated liposomal doxorubicin (PLD) in combination, versus PLD alone, in subjects with platinum-resistant ovarian cancer

LBA5012b

Background: EC145, a conjugate of folic acid and desacetylvinblastine hydrazide binds with high affinity to the folate receptor (FR), found on > 90% of epithelial ovarian cancers. This abstract reports interim data on an international randomized, phase II study of EC145 + PLD compared with PLD alone, in women with platinum-resistant ovarian cancer. An independent Data Safety Monitoring Board (DSMB) has conducted a prespecified interim analysis on PFS and safety with results reported herein.

Methods: Women ≥ 18 with ECOG PS of 0-2 and ≤ 2 prior systemic cytotoxic regimens were randomized to receive EC145 (2.5 mg IV weeks 1 and 3) + PLD (50 mg/m2 IBW IV q 28 days) or PLD (50 mg/m2 IBW IV q 28 days) alone until progression or death.

Results: The interim analysis occurred after the 46th event out of a planned study total of 95 progressions or deaths. Demographic characteristics at screening such as age, cancer type, residual tumor after debulking, prior therapy, CA-125 and time from diagnosis were balanced between arms. RECIST mean sum tumor length was longer for the combination arm (122.7 mm vs. 81.3 mm). There was no statistical difference between study arms with regard to total adverse events, serious adverse events, or the number of subjects reporting at least one treatment-emergent drug-related serious adverse event resulting in discontinuation. The Table displays the results of the interim analysis of PFS. At the interim, there is also a trend toward benefit in overall survival for the combination arm with HR = 0.425 (p value of 0.064).

Conclusions: Results indicate a greater than doubling in median PFS for women with platinum-resistant ovarian cancer receiving EC145 and PLD over those receiving PLD alone. These interim data suggest that EC145 and PLD is the first combination to show a statistically significant delay in progression-free survival over standard therapy in women with platinum-resistant ovarian cancer.

[Table: see text]

[Table: see text]

Providers' knowledge, practices, and barriers related to genital herpes testing for patients with HIV

This cross-sectional study explored the knowledge, practice, and reported barriers related to genital herpes testing among 102 health care providers who treat people living with HIV in the United States. Twelve percent reported always testing HIV-infected patients for genital herpes, 65% sometimes or usually tested, and 23% rarely or never tested for genital herpes. Seventy-five percent said testing was not standard of care. Providers were more likely to recommend a herpes test if the patient had symptoms (94%) or had a partner with herpes (83%) and were less likely to recommend testing if patients had no partners (60%) or would rather not know (49%). Our work adds to the growing body of literature on herpes simplex virus-HIV coinfection by documenting that (a) providers often do not screen for genital herpes, (b) knowledge of appropriate diagnostic evaluation is limited, and (c) many clinicians report the lack of clear guidelines is a barrier to testing.