Training during the COVID-19 pandemic: the experience of public health registrars in the London and Kent, Surrey, Sussex training programme

BACKGROUND

Public Health registrars (SpRs) were an important component of the workforce that contributed to the COVID-19 response. This study explores their contribution and the impact the early stages of the pandemic had on their learning and training.

METHODS

Data were collected from SpRs in the London and Kent, Surrey, Sussex training programme between July and September 2020 through a mixture of questionnaires and semi-structured interviews. A thematic analysis of interview transcripts was undertaken to identify themes.

RESULTS

35/128 SpRs responded to the survey and 11 were interviewed. SpRs were placed across a range of organizations and made a significant contribution to the COVID-19 response. Overall, SpRs learned important skills but working on the response may for some have impacted negatively on training. A number of facilitators and barriers to learning were identified.

CONCLUSION

The study findings highlight the opportunities for learning created by the pandemic. However, changing projects and the desire of SpRs to contribute to the response meant the impacts on training were mixed. Future deployment of SpRs should consider the balance of responsibility and pace when delegating work, as well as the need to supervise effectively and support remote working to maintain good mental wellbeing.

Responding to eruptive transitions during the 2020-2021 eruption of La Soufrière volcano, St. Vincent

A critical challenge during volcanic emergencies is responding to rapid changes in eruptive behaviour. Actionable advice, essential in times of rising uncertainty, demands the rapid synthesis and communication of multiple datasets with prognoses. The 2020-2021 eruption of La Soufrière volcano exemplifies these challenges: a series of explosions from 9-22 April 2021 was preceded by three months of effusive activity, which commenced with a remarkably low level of detected unrest. Here we show how the development of an evolving conceptual model, and the expression of uncertainties via both elicitation and scenarios associated with this model, were key to anticipating this transition. This not only required input from multiple monitoring datasets but contextualisation via state-of-the-art hazard assessments, and evidence-based knowledge of critical decision-making timescales and community needs. In addition, we share strategies employed as a consequence of constraints on recognising and responding to eruptive transitions in a resource-constrained setting, which may guide similarly challenged volcano observatories worldwide.

Supporting sAFE and GradUAl ReDuctIon of loNG-term BenzodiaZepine Receptor Agonist uSe: development of the SAFEGUARDING-BZRAs toolkit using a co-design approach

Introduction

Long-term benzodiazepine receptor agonist (BZRA) use (>3 months) persists worldwide and poses risks of harm. Effective interventions are needed to address this issue.

Aim

To develop an intervention to support discontinuation of long-term benzodiazepine receptor agonist (BZRA) use.

Methods

The intervention development process built on previous qualitative work that used the Theoretical Domains Framework (TDF) to explore perceived barriers and facilitators to discontinuing long-term BZRA use (1). A co-design approach was used whereby lay individuals and professionals worked as equals during the research process based on principles of authentic participation and collaboration (2). The co-design team included five ‘experts by lived experience’ with experience of long-term BZRA use who previously provided input on other related work as patient and public involvement representatives or responded to an expression of interest call on social media. Two online co-design team meetings were held. During the first meeting, a summary of previous findings was presented together with a long-list of behaviour change techniques (BCTs) generated using established mapping matrices in which BCTs were reliably allocated to the TDF. Each team member independently documented their decision as to whether each BCT should be included in a short-list for potential inclusion in the final intervention using online polling software. The a priori decision rule was that 70% of team members had to agree regarding the inclusion/exclusion of a BCT. All other BCTs were then discussed at a follow-up meeting. A finalised list of BCTs for inclusion in the intervention was agreed at the second meeting using a consensus-based approach involving the same decision rule. Potential ways in which BCTs could be operationalised were then discussed.

Results

Thirty BCTs were discussed and six BCTs were excluded. For example, team members recommended avoiding ‘Social comparison’ as individual circumstances and experiences of discontinuation and associated withdrawal symptoms are unique and not directly comparable. Given the number of included BCTs, the co-design team recommended presenting them as a toolkit. The SAFEGUARDING-BZRAs (Supporting sAFE and GradUAl ReDuctIon of loNG-term BenzodiaZepine Receptor Agonist uSe) toolkit comprises 24 BCTs: ‘Goal setting (behaviour)’, ‘Review behaviour goal(s)’, ‘Review outcome goal(s)’, ‘Feedback on behaviour’, ‘Self-monitoring of behaviour’, ‘Social support (practical)’, ‘Social support (emotional)’, ‘Information about health consequences’, ‘Monitoring of emotional consequences’, ‘Information about emotional consequences’, ‘Prompts/cues’, ‘Habit reversal’, ‘Graded tasks’, ‘Pros and cons’, ‘Comparative imagining of future outcomes’, ‘Social reward’, ‘Self-reward’, ‘Reduce negative emotions’, ‘Distraction’, ‘Adding objects to the environment’, ‘Body changes’, ‘Verbal persuasion about capability’, ‘Focus on past success’ and ‘Credible source’. The toolkit includes recommendations targeted at primary care-based clinicians for operationalising each BCT to support BZRA discontinuation.

Conclusion

The SAFEGUARDING-BZRAs toolkit has been developed using a systematic, theory-based approach that addresses identified limitations of previous research (e.g. lack of detailed intervention description). In terms of limitations, it is possible that a different group of individuals may have developed a different type of intervention. To overcome this, a priori decision rules were used for decision making. Further research is needed to assess the toolkit’s usability and acceptability by service users and clinicians.

References

(1) Lynch et al. Health Expect. [in press] DOI: 10.1111/hex.13392.

(2) O’Donnell et al. BMC Health Serv Res. 2019;19(1):797

O66: FLOW CYTOMETRIC AND RNA SEQUENCED UNCOUPLING OF TUMOUR-INFILTRATING LYMPHOCYTE CHECKPOINT EXPRESSION AND MISMATCH REPAIR STATUS IN COLORECTAL CANCER

Introduction

Selection criteria for immunotherapy with checkpoint blockade in colorectal cancer are currently based on mismatch repair status. However, intra-tumoral T cell response varies among patients with the same MMR status. Inhibitory checkpoint expression on tumour-infiltrating lymphocytes in microsatellite stable and unstable CRC is unknown.

Method

Flow cytometric analysis and single-cell RNA sequencing, using the 10x genomic platform, were performed ex vivo on tumour and uninvolved colonic tissue samples from patients undergoing surgical resection for colorectal cancer. Inhibitory checkpoint expression (PD-1) and functional status of isolated populations of TILs were analysed.

Result

Conventional and unconventional tissue-resident T cells were enriched in tumour samples compared to uninvolved healthy colonic tissue. Upregulation of PD-1 expression on TILs was observed in all patients, however the % upregulation varied among those with the same MMR status. A proportion of MSS tumours were found to have high levels of PD-1 expression, while a subset of MSI tumours had low PD-1 expression. Functional studies of cytotoxicity demonstrated varying TIL production of IFNg, TNFa and amphiregulin in patients with the same MMR status.

Conclusion

TIL profile (infiltration pattern, checkpoint expression and functional status) differs among patients with the same MMR status. A subset of ‘hot’ immunogenic MSS tumours exist that may respond to checkpoint blockade. Characterisation of TIL profile represents a more accurate method of selecting patients likely to derive benefit. Abbrev. CRC Colorectal cancer, MMR Mismatch repair, TIL Tumour-infiltrating lymphocytes, MSS Microsatellite stable, MSI Microsatellite unstable, IFNg Interferon-gamma, TNFa Tumour necrosis factor alpha

Take-home message

A subset of immunogenic microsatellite stable colorectal tumours exist that may respond to checkpoint blockade. Mismatch repair status alone does not accurately predict response to immunotherapy.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Glucagon-like peptide-1 (GLP-1) and the regulation of human invariant natural killer T cells: lessons from obesity, diabetes and psoriasis

AIMS/HYPOTHESIS

The innate immune cells, invariant natural killer T cells (iNKT cells), are implicated in the pathogenesis of psoriasis, an inflammatory condition associated with obesity and other metabolic diseases, such as diabetes and dyslipidaemia. We observed an improvement in psoriasis severity in a patient within days of starting treatment with an incretin-mimetic, glucagon-like peptide-1 (GLP-1) receptor agonist. This was independent of change in glycaemic control. We proposed that this unexpected clinical outcome resulted from a direct effect of GLP-1 on iNKT cells.

METHODS

We measured circulating and psoriatic plaque iNKT cell numbers in two patients with type 2 diabetes and psoriasis before and after commencing GLP-1 analogue therapy. In addition, we investigated the in vitro effects of GLP-1 on iNKT cells and looked for a functional GLP-1 receptor on these cells.

RESULTS

The Psoriasis Area and Severity Index improved in both patients following 6 weeks of GLP-1 analogue therapy. This was associated with an alteration in iNKT cell number, with an increased number in the circulation and a decreased number in psoriatic plaques. The GLP-1 receptor was expressed on iNKT cells, and GLP-1 induced a dose-dependent inhibition of iNKT cell cytokine secretion, but not cytolytic degranulation in vitro.

CONCLUSIONS/INTERPRETATION

The clinical effect observed and the direct interaction between GLP-1 and the immune system raise the possibility of therapeutic applications for GLP-1 in inflammatory conditions such as psoriasis.

Preadipocyte factor-1 is associated with metabolic profile in severe obesity

CONTEXT

Dysfunctional adipose tissue has been proposed as a key pathological process linking obesity and metabolic disease. Preadipocyte factor-1 (Pref-1) has been shown to inhibit differentiation in adipocyte precursor cells and could thereby play a role in determining adipocyte size, adipose tissue functioning, and metabolic profile in obese individuals.

OBJECTIVE

We hypothesized that adipose tissue from metabolically healthy obese (MHO) and matched metabolically unhealthy obese individuals would demonstrate distinct differences in relation to Pref-1 expression, adipocyte size, and inflammatory markers.

DESIGN, SETTING, AND PATIENTS

This was a cross-sectional study, investigating obese patients undergoing bariatric surgery at a tertiary referral centre. Patients included 12 MHO and 17 age- and body mass index-matched metabolically unhealthy obese individuals.

MAIN OUTCOME MEASURES

Pref-1, monocyte chemotactic protein-1, TNF-α, granulocyte colony-stimulating factor, IL-6, and adiponectin levels, macrophage numbers, and adipocyte size were measured in omental and subcutaneous adipose tissue.

RESULTS

The MHO group had a lower level of Pref-1 (per 1000 adipocytes) in both subcutaneous [160 (136-177) versus 194 (153-355); P < 0.05] and omental adipose tissue [102 (32-175) versus 194 (100-350); P < 0.005]. This was associated with lower numbers of macrophages, lower levels of TNF-α, monocyte chemotactic protein-1, and granulocyte colony-stimulating factor, and higher levels of adiponectin. Omental Pref-1 showed strong correlations with adipocyte size (r = 0.67, P < 0.0005) and metabolic and adipokine parameters, including percent fatty liver (r = 0.62, P < 0.005), fasting glucose (r = 0.68, P < 0.0005), triglyceride (r = 0.60, P < 0.005), high-density lipoprotein cholesterol (r = -0.46, P < 0.05), and adiponectin (r = -0.71, P < 0.05).

CONCLUSION

Adipose tissue in MHO individuals had lower levels of Pref-1, a known inhibitor of preadipocyte differentiation, and a more favorable inflammatory profile. These factors may be key to protecting this subgroup of obese individuals from the adverse metabolic profile associated with excess adiposity.

Natural Killer Cells in Psoriasis

Psoriasis is one of the most common immune-mediated disorders. There is evidence that it is mediated by Th1 and, more recently, Th17 cells. The cytokine pattern, particularly the dominance of TNF-α, implicates the innate immune system in psoriasis pathogenesis. Of the many components of the innate immune system known to be involved in psoriatic lesions, natural killer and natural killer T cells appear to have a unique role. We review the evidence supporting a role for natural killer cells in psoriasis.

Cells with haematopoietic stem cell phenotype in adult human endometrium: relevance to infertility?

BACKGROUND

Uterine lymphoid cell repertoires are specialized in order to meet the twin demands of successful pregnancy and local immunosurveillance. The possibility that some of these populations might differentiate locally from progenitor cells has been proposed.

METHODS

Endometrial tissue from women with a history of infertility as well as fertile controls was examined for haematopoietic stem cells (HSCs) and lymphoid progenitors using three-colour flow cytometry.

RESULTS

Significant populations of phenotypic HSCs (CD34+ CD45+ ) were detected in all samples, a high proportion of which co-expressed the differentiation marker CD45RA (45.7%), indicating ongoing differentiation. Almost 30% of uterine HSCs co-expressed CD56 and 44% co-expressed CD7, suggesting the presence of lymphoid progenitors. Small proportions expressed CD127 and CD122, receptors for interleukin (IL)-7 and IL-15, respectively. HSC numbers were similar in the endometrial samples from fertile and infertile women. However, the proportion co-expressing the natural killer (NK) antigen CD56 was significantly increased compared with HSCs found in the endometrium of fertile controls (P = 0.002).

CONCLUSIONS

This is the first demonstration of cells with an HSC phenotype in the human endometrium, and increased proportions of NK progenitors in endometrium of women with infertility suggests a dysregulation of this pathway that may contribute to infertility.

Long-term donepezil treatment in 565 patients with Alzheimer's disease (AD2000): randomised double-blind trial

BACKGROUND

Cholinesterase inhibitors produce small improvements in cognitive and global assessments in Alzheimer's disease. We aimed to determine whether donepezil produces worthwhile improvements in disability, dependency, behavioural and psychological symptoms, carers' psychological wellbeing, or delay in institutionalisation. If so, which patients benefit, from what dose, and for how long?

METHODS

565 community-resident patients with mild to moderate Alzheimer's disease entered a 12-week run-in period in which they were randomly allocated donepezil (5 mg/day) or placebo. 486 who completed this period were rerandomised to either donepezil (5 or 10 mg/day) or placebo, with double-blind treatment continuing as long as judged appropriate. Primary endpoints were entry to institutional care and progression of disability, defined by loss of either two of four basic, or six of 11 instrumental, activities on the Bristol activities of daily living scale (BADLS). Outcome assessments were sought for all patients and analysed by logrank and multilevel models.

FINDINGS

Cognition averaged 0.8 MMSE (mini-mental state examination) points better (95% CI 0.5-1.2; p<0.0001) and functionality 1.0 BADLS points better (0.5-1.6; p<0.0001) with donepezil over the first 2 years. No significant benefits were seen with donepezil compared with placebo in institutionalisation (42% vs 44% at 3 years; p=0.4) or progression of disability (58% vs 59% at 3 years; p=0.4). The relative risk of entering institutional care in the donepezil group compared with placebo was 0.97 (95% CI 0.72-1.30; p=0.8); the relative risk of progression of disability or entering institutional care was 0.96 (95% CI 0.74-1.24; p=0.7). Similarly, no significant differences were seen between donepezil and placebo in behavioural and psychological symptoms, carer psychopathology, formal care costs, unpaid caregiver time, adverse events or deaths, or between 5 mg and 10 mg donepezil.

INTERPRETATION

Donepezil is not cost effective, with benefits below minimally relevant thresholds. More effective treatments than cholinesterase inhibitors are needed for Alzheimer's disease.

Difficult airway management of a child impaled through the neck

We report the difficult airway management of a child impaled through the neck by a wooden plant support. The various options are discussed and the involvement of experienced personnel together with a clear preformulated plan of action is stressed.

Activation of alpha(v)beta3-vitronectin binding is a multistage process in which increases in bond strength are dependent on Y747 and Y759 in the cytoplasmic domain of beta3

Integrin receptors serve as mechanical links between the cell and its structural environment. Using alpha(v)beta3 integrin expressed in K562 cells as a model system, the process by which the mechanical connection between alpha(v)beta3 and vitronectin develops was analyzed by measuring the resistance of these bonds to mechanical separation. Three distinct stages of activation, as defined by increases in the alpha(v)beta3-vitronectin binding strength, were defined by mutational, biochemical, and biomechanical analyses. Activation to the low binding strength stage 1 occurs through interaction with the vitronectin ligand and leads to the phosphorylation of Y747 in the beta3 subunit. Stage 2 is characterized by a 4-fold increase in binding strength and is dependent on stage1 and the phosphorylation of Y747. Stage 3 is characterized by a further 2.5-fold increase in binding strength and is dependent on stage 2 events and the availability of Y759 for interaction with cellular proteins. The Y747F mutant blocked the transition from stage 1 to stage 2, and the Y759F blocked the transition from stage 2 to stage 3. The data suggest a model for tension-induced activation of alpha(v)beta3 integrin.

Distinct ligand-binding modes for integrin alpha(v)beta(3)-mediated adhesion to fibronectin versus vitronectin

Cell surface integrins can adopt distinct conformations in response to ligand binding and intracellular signals. Several integrins including alpha(v)beta(3) can bind to multiple ligands. The binding of alpha(v)beta(3) to fibronectin and vitronectin was used as a model to determine whether the same or distinct forms of the receptor were utilized in strong binding to the two different ligands. A spinning-disc device was used to measure the relative strength of the alpha(v)beta(3)-ligand bonds. The initial binding reaction for both ligands occurred in the absence of metabolic energy and resulted in a strong adhesion to fibronectin but a weak adhesion to vitronectin. Increases in the strength of the alpha(v)beta(3)-vitronectin bond required phosphorylation of the beta(3) cytoplasmic domain, intracellular signals, and the binding of cytoskeletal proteins to cytoplasmic domains of beta(3) controlled by Tyr-747 and Tyr-759. In contrast, alpha(v)beta(3)-mediated adhesion to fibronectin was unaffected by phorbol 12-myristate 13-acetate, mutations of Tyr-747 and Tyr-759 to phenylalanine, or availability of metabolic energy. This suggests that strong adhesion to fibronectin used the initial binding conformation, whereas strong binding to vitronectin required signaling-induced changes in the conformation of alpha(v)beta(3).

Dopexamine hydrochloride does not modify hemodynamic response or tissue oxygenation or gut permeability during abdominal aortic surgery

PURPOSE

To assess the effects of intraoperative infusion of dopexamine (a DA-1 and B2 adrenoreceptor agonist) on hemodynamic function, tissue oxygen delivery and consumption, splanchnic perfusion and gut permeability following aortic cross- clamp and release.

METHODS

In a randomised double blind controlled trial 24 patients scheduled for elective infrarenal abdominal aortic aneurysm repair were studied in two centres and were assigned to one of two treatment groups. Group I received a dopexamine infusion starting at 0.5 microg x kg(-1) x min(-1) increased to 2 microg x kg(-1) x min(-1) maintaining a stable heart rate; Group II received a placebo infusion titrated in the same volumes following induction of anesthesia. Measured and derived hemodynamic data, tissue oxygen delivery and extraction and gut permeability were recorded at set time points throughout the procedure.

RESULTS

Dopexamine infusion (0.5 -2 microg x kg x min(-1)) was associated with enhanced hemodynamic function (MAP 65 +/- 5.5 vs 92 +/- 5.7 mm Hg, P = <0.05) only during the period of aortic cross clamping. However, during the most part of infrarenal abdominal aortic surgery, dopexamine did not reduce systemic vascular resistance index, mean arterial pressure nor oxygen extraction compared with the control group. The lactulose/ rhamnose permeation ratio was elevated above normal in both groups (0.22 and 0.29 in groups I and II respectively).

CONCLUSIONS

Dopexamine infusion (0.5 -2 microg x kg(-1) x min(-1)) did not enhance hemodynamic function and tissue oxygenation values during elective infrarenal abdominal aortic aneurysm repair.

Chorionic villus sampling before multifetal pregnancy reduction

OBJECTIVE

This study was undertaken to determine the technical feasibility and accuracy of chorionic villus sampling before multifetal pregnancy reduction and to determine whether sampling increases the pregnancy loss rate after the reduction procedure.

STUDY DESIGN

Between January 22, 1986, and January 20, 2000, a total of 1183 patients underwent first-trimester multifetal pregnancy reduction at Mount Sinai Medical Center. Chorionic villus sampling was attempted in 86 patients before the reduction procedure. Information on the technical success and accuracy of chorionic villus sampling, as well as pregnancy outcome, was collected on all patients. Pregnancy loss rates before 24 weeks' gestation in patients undergoing chorionic villus sampling before multifetal pregnancy reduction were compared with rates in patients not undergoing sampling.

RESULTS

Chorionic villus sampling was successfully completed in 85 (98.8%) of 86 patients in whom sampling was attempted. Of 166 fetuses, 165 (99.4%) were successfully sampled. Of 165 fetuses, 3 (1.8%) had karyotypic abnormalities. Sampling errors were probably made in 2 (1.2%) of 165 fetuses. Of the 73 patients who have been delivered or are beyond 24 weeks' gestation, only 1 patient (1.4%) had a pregnancy loss after the multifetal pregnancy reduction.

CONCLUSIONS

Chorionic villus sampling before multifetal pregnancy reduction is technically feasible and accurate, with an acceptably low sampling error rate. Chorionic villus sampling before multifetal pregnancy reduction appears to be safe and does not increase the risk of loss after the reduction procedure.

Systematic identification and intervention for reading difficulty: case studies of children with EAL

Literacy underpins education. There is now very widespread concern over standards of literacy for children from multi-cultural backgrounds, who are learning English as a second or subsequent language, and who may have special educational needs. Research evidence suggests that the earlier children's difficulties can be identified, the more effective (and cost-effective) intervention will be, provided that the intervention is tailored to the child's abilities and skills. Nicolson and Fawcett have developed systematic procedures for identifying children at risk for reading difficulty, together with systematic teaching strategies to overcome reading difficulty. In this paper we present case studies of children with EAL (English as an additional language) drawn from a controlled study using computer interventions with secondary school children. Our findings indicate that children with EAL may be more resistant to remediation than some children with learning difficulties. The prognosis is more problematic for children with both EAL and dyslexia.

Magma flow instability and cyclic activity at soufriere hills volcano, montserrat, british west indies

Dome growth at the Soufriere Hills volcano (1996 to 1998) was frequently accompanied by repetitive cycles of earthquakes, ground deformation, degassing, and explosive eruptions. The cycles reflected unsteady conduit flow of volatile-charged magma resulting from gas exsolution, rheological stiffening, and pressurization. The cycles, over hours to days, initiated when degassed stiff magma retarded flow in the upper conduit. Conduit pressure built with gas exsolution, causing shallow seismicity and edifice inflation. Magma and gas were then expelled and the edifice deflated. The repeat time-scale is controlled by magma ascent rates, degassing, and microlite crystallization kinetics. Cyclic behavior allows short-term forecasting of timing, and of eruption style related to explosivity potential.

Reduction of distress in children undergoing sexual abuse medical examination

A participant modeling film to reduce distress in children (5 to 13 years old) undergoing sexual abuse medical examination was tested. Twenty-one children viewing the participant modeling film reported less fear after film viewing and were behaviorally less distressed and more compliant, as rated by nurses and mothers, during gynecological examination than 21 children viewing a nonrelevant film.

First-trimester growth restriction and fetal aneuploidy: the effect of type of aneuploidy and gestational age

OBJECTIVE

Our purpose was to determine the effect of type of aneuploidy and gestational age on first-trimester fetal growth.

STUDY DESIGN

Crown-rump length measurement was obtained in pregnancies undergoing chorionic villus sampling in three large prenatal diagnosis centers. One hundred forty-four aneuploid fetuses, from 9 to 13 weeks' gestation, were compared with 440 matched control fetuses for evidence of crown-rump length shortening. Shortening was defined by the observed/expected crown-rump length. Expected values of crown-rump length based on last menstrual period were obtained from regression equations generated from a separate normal group. Threshold values for aneuploidy screening were determined on the basis of receiver-operator characteristic curves.

RESULTS

There was significant crown-rump length shortening in trisomy 18 compared with normal fetuses, with observed/expected values < or = 0.80 (odds ratio 13.78, 95% confidence interval 5.64 to 33.88, p < 0.000001); for trisomy 13 the observed/expected crown-rump length was < or = 0.90 (odds ratio 3.64, 95% confidence interval 1.08 to 12.96, p < 0.03). There was no significant shortening of crown-rump length in Down syndrome, with observed/expected values < or = 0.92 (odds ratio 0.86, 95% confidence interval 0.50 to 1.47, p = 0.6). With shortened crown-rump length (observed/expected value < 0.86) the risk of any aneuploidy is increased (odds ratio 2.52, 95% confidence interval 1.6 to 3.96, p < 0.0001). When the first-trimester crown-rump length was shortened by > or = 14 mm, the aneuploidy risk was high (odds ratio 9.04, 95% confidence interval 3.26 to 28.67, p < 0.00001).

CONCLUSION

In the first trimester fetuses with trisomy 18 and 13 appear to be growth restricted, in contrast to fetuses with trisomy 21. In at-risk pregnancies crown-length that is shorter than expected significantly increase the odds that aneuploidy is present.

Twin pregnancies conceived by assisted reproductive techniques: maternal and neonatal outcomes

OBJECTIVE

To determine whether twin pregnancies conceived by assisted reproductive techniques are at increased risk for obstetric complications or perinatal morbidity.

METHODS

A computerized perinatal data base was reviewed for all twin pregnancies managed by private obstetricians and delivered between 1990 and 1995. The obstetric and neonatal outcomes of those conceived following in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT) were compared to the outcomes of those conceived spontaneously.

RESULTS

There were 105 twin deliveries following IVF or GIFT and 279 following natural fertilization. Discordant birth weight and low birth weight occurred more frequently in pregnancies conceived by IVF or GIFT (adjusted odds ratio [OR] 2.11, 95% confidence interval [CI] 1.14, 3.91; OR 1.65, 95% CI 0.98, 2.79, respectively). Elective cesarean delivery was more frequent in twin pregnancies conceived after IVF GIFT (relative risk [RR] 4.02, 95% CI 1.28, 12.6). There were no statistically significant differences in the frequency of antepartum or intrapartum complications, preterm delivery, or mean gestational age at delivery. There was no statistically significant increase in the frequency of neonatal complications among infants born after IVF GIFT.

CONCLUSION

Although twin pregnancies following IVF or GIFT are more likely to result in discordant birth weight infants, the perinatal outcome is comparable to that of spontaneously conceived twin pregnancies.

Pregnancy outcome at age 40 and older

OBJECTIVE

To examine pregnancy outcome among women age 40 years and older.

METHODS

A retrospective cohort study, including 1404 pregnant women at least 40 years of age and 6978 controls age 20-29 years, was conducted. The two groups were stratified, according to parity, to facilitate separate analysis. Associations between maternal age and pregnancy outcomes were assessed with the contingency chi 2 or two-tailed Fisher exact test. Multiple logistic regression was used to evaluate these associations and allowed for calculation of adjusted odds ratios (OR).

RESULTS

Older gravidas were more likely to develop gestational diabetes (nulliparas: OR 2.7, 95% confidence interval [CI] 1.9-3.7; multiparas: OR 3.8, 95% CI 2.7-5.4), preeclampsia (nulliparas: OR 1.8, 95% CI 1.3-2.6; multiparas: OR 1.9, 95% CI 1.2-2.9), and placenta previa (nulliparas: OR 13.0, 95% CI 4.8-35.0; multiparas: OR 6.4, 95% CI 2.6-15.6). Older women were also at increased risk for cesarean delivery (nulliparas: OR 3.1, 95% CI 2.6-3.7; multiparas: OR 3.3, 95% CI 2.6-4.1), operative vaginal delivery (nulliparas: OR 2.4, 95% CI 1.9-2.9; multiparas: OR 1.5, 95% CI 1.2-1.9), and induction of labor (nulliparas: OR 1.5, 95% CI 1.2-1.8; multiparas: OR 1.4, 95% CI 1.1-1.7). Older nulliparas had an increased incidence of abnormal labor patterns (OR 1.4, 95% CI 1.2-1.7), neonatal intensive care unit admissions (OR 1.6, 95% CI 1.2-2.2), and low 1-minute Apgar scores (OR 2.3, 95% CI 1.1-4.9). Older multiparas were more likely to experience fetal distress (OR 2.0, 95% CI 1.4-2.8), antepartum vaginal bleeding (OR 1.8, 95% CI 1.1-3.1), and preterm premature rupture of membranes (OR 1.7, 95% CI 1.1-2.9).

CONCLUSION

Although maternal morbidity was increased in the older gravidas, the overall neonatal outcome did not appear to be affected.

Antenatal management of alloimmune thrombocytopenia with intravenous gamma-globulin: a randomized trial of the addition of low-dose steroid to intravenous gamma-globulin

OBJECTIVES

Our purposes were to investigate maternal infusions of intravenous gamma-globulin, to prevent intracranial hemorrhage, and to determine whether 1.5 mg dexamethasone and 60 mg prednisone per day add to the effect of intravenous gamma-globulin.

STUDY DESIGN

Fifty-four women with alloimmune thrombocytopenia and thrombocytopenic fetuses were randomized to intravenous gamma-globulin 1 gm/kg per week with or without dexamethasone. Nonresponders after 4 to 6 weeks received continued intravenous gamma-globulin plus 60 mg of prednisone per day ("salvage").

RESULTS

Dexamethasone did not add to the effect of intravenous gamma-globulin. Overall, there was a mean platelet increase from the first to the second fetal blood sampling of 36,000/microliters (n = 47) and from the first fetal blood sampling to birth of 69,000/microliters (n = 54). A total of 62% to 85% of fetuses responded. There were no intracranial hemorrhages. "Salvage" increased the platelet count in 5 of 10 nonresponders to intravenous gamma-globulin.

CONCLUSION

Intravenous gamma-globulin treatment is appropriate for thrombocytopenic fetuses with alloimmune thrombocytopenia before use of weekly in utero platelet transfusions, even in severe thrombocytopenia.

The current status of multifetal pregnancy reduction

The number of women conceiving three or more fetuses has increased dramatically as a result of successful infertility therapy with ovulation-inducing agents and assisted reproductive technology. Higher-order multiple gestations have an increased risk of premature delivery and its attendant sequelae of increased neonatal mortality or irreversible morbidity. Multifetal pregnancy reduction is a procedure designed to decrease the increased propensity to deliver very prematurely in these patients by reducing the number of live fetuses they are carrying. The procedure has proved to be both safe and effective, and pregnancies reduced to twins proceed as if that were the number of fetuses originally conceived. Nevertheless, this invasive procedure does have the potential to result in loss of the entire pregnancy and causes considerable emotional distress for some couples who view it as their "least bad" alternative. The medical benefits of performing multifetal pregnancy reduction in women with four or more fetuses seem fairly well established, but this is less true for triplets. Serious attention should be paid to reducing the number of higher-order multiple pregnancies resulting from infertility therapy. In the meantime, when three or more fetuses have been conceived, multifetal pregnancy reduction offers a reasonable option to patients whose only choices in the past were either to accept the risk of delivering extremely prematurely or to terminate the entire pregnancy.

The clinical outcome of preterm premature rupture of membranes in twin versus singleton pregnancies

The purpose of this study was to determine the clinical outcome of preterm premature rupture of the membranes (PPROM) in twin versus singleton pregnancies at less than or equal to 36 weeks' gestation. A retrospective cohort study was conducted in 116 twin pregnancies with PPROM at less than or equal to 36 weeks' gestational age and 116 matched singleton pregnancies. The two groups were analyzed for differences in maternal demographics and perinatal and neonatal outcome. Perinatal and neonatal outcomes were similar in the two groups. The median latency period, however, was significantly decreased in the twin group (11.4 hours, Inter Quartile Range: 6.3-26.4) versus the singleton group (19.5 hours, Inter Quartile Range: 10.2-49.3, p < 0.05). The latency period in each group was notably longer when PPROM occurred at less than 30 weeks' gestation, but was still shorter in the twin pregnancies (27.6 hours, Inter Quartile Range: 20-307 versus 75.1 hours, Inter Quartile Range: 15-189, p < 0.05). Twin pregnancies with PPROM at less than or equal to 36 weeks' gestational age have a decreased latency period when compared to matched singletons. The perinatal and neonatal outcomes, however, are similar.

Preterm delivery after selective termination in twin pregnancies

OBJECTIVE

To determine the effect of selective termination of an abnormal twin on the rate of preterm delivery.

METHODS

The study group consisted of 69 patients with twin pregnancies who underwent selective termination between 1987-1994. The comparison groups consisted of singleton (n = 42,362) and twin pregnancies (n = 825) delivered at our institution during the same period. The data were analyzed by Chi2 and Fisher exact test, as appropriate. P < .05 was considered significant. Adjusted odds ratios(OR) and 95% confidence intervals (CI) were calculated by multiple logistic regression.

RESULTS

Terminating the presenting twin was associated with a significantly higher risk of delivery before 37 weeks (adjusted OR 4.1, 95% CI 1.4-12.3) and low birth weight (adjusted OR 3.8, 95% CI 1.3-11.4) compared with terminating the nonpresenting twin. When the termination was performed at or after 20 weeks' gestation, only the risk of preterm premature rupture of the membranes or preterm labor was significantly increased (adjusted OR 3.7, 95% CI 1.2-11.5). Selective termination patients had a lower rate of preterm delivery than twin pregnancies (40 versus 58%, P < .005) but higher than singleton pregnancies (40 versus 10%,P < .001).

CONCLUSION

Selective termination of the presenting twin at 20 weeks or later was associated with a worse perinatal outcome than terminating the nonpresenting twin or performing the procedure before 20 weeks.

A sensitive and specific PCR method to detect Helicobacter felis in a conventional mouse model

Although many detection methods have been used to determine Helicobacter colonization in small animal models, the sensitivity and specificity of these detection methods are limited. To improve the Helicobacter felis conventional mouse model for accurate evaluation of therapeutic regimens, we developed a PCR for detection of, and a competitive PCR for quantitation of, H. felis in viral antibody-free (VAF) mice. The PCR was based on the H. felis 16S rRNA gene. An internal control DNA was used for competitive quantitation of the PCR. VAF conventional Swiss-Webster mice were infected with an H. felis culture by oral gavage. At various times after H. felis challenge and therapy, stomach mucosa was collected and evaluated by PCR. PCR detected approximately 50 to 100 H. felis cells per mouse stomach and showed no cross-reaction with other bacteria commonly found in mouse stomachs. Colonization of H. felis in the mouse stomach was confirmed by culture isolation from germfree mice and histological examination of VAF mice. Response to therapy in this H. felis model correlated well with results seen in human clinical trials with H. pylori. A model utilizing PCR detection which may be useful for discovering new antibiotics and/or vaccines against Helicobacter ulcer disease has been developed.

International, collaborative experience of 1789 patients having multifetal pregnancy reduction: a plateauing of risks and outcomes

OBJECTIVE

To develop the most up-to-date, complete data base of multifetal pregnancy reduction (MFPR) from cases, and to provide the best counseling for couples with multifetal pregnancies.

METHODS

From nine centers in five countries, 1789 completed MFPR cases were collected and outcomes evaluated. Pregnancy losses were defined as through 24 weeks and deliveries categorized in groups of 25-28, 29-32, 33-36, and 37 or more weeks.

RESULTS

Overall, the pregnancy loss rate was 11.7% but varied from a low of 7.6% for triplets to twins and increased with each additional starting number to 22.9% for sextuplets or higher. Early premature deliveries (25-28 weeks) were 4.5% and varied with starting number. Loss rates by finishing number were highest for triplets and lowest for twins, but gestational age at delivery was highest for singletons.

CONCLUSIONS

Multifetal pregnancy reduction has been shown to be a safe and effective method to improve outcome in multifetal pregnancies. Outcomes are worse with higher-order gestations and support the need for continued vigilance of fertility therapy.

Accuracy of ultrasound estimation of fetal weight in multiple pregnancies

Our objective was to assess the accuracy of ultrasonographic estimation of fetal weight in twins and triplets as compared to singleton pregnancies. Retrospective analysis was undertaken of ultrasound data of all fetuses who underwent an examination within 1 week of delivery (singletons 1832, twins 518, triplets 51). At birth weights below 2500 g, there was a significant overestimation of fetal weight in twins as compared to singletons, but the accuracy of the estimate was the same, except in twins between 1500 and 2499 g, when the weight was based on abdominal circumference and femur length alone. At birth weights of more than 2500 g, no difference was detected between twins and singletons. At all birth weights below 2500 g, the accuracy of weight estimation in triplets was equal to that in singletons and there were no triplets above this weight. We conclude that ultrasonographic estimation of fetal weight is as accurate in twins and triplets as it is in singletons.

Maternal serum levels of alpha-fetoprotein and fetal fibronectin as markers of labor in the third trimester

Unexplained elevations of maternal serum alpha-fetoprotein (MSAFP) in the second trimester have been found to be associated with a two- to fourfold increase in the rate of preterm delivery, but the sensitivity is low. Therefore, we reasoned that MSAFP levels in the third trimester could prove to be a more useful biochemical marker to predict labor. The presence of placental and membrane-derived fetal fibronectin (FFN) in cervicovaginal secretions has recently been shown to predict preterm delivery with a sensitivity of 81.7% and specificity of 82.5%. We postulated that damage to membranes and microscopic breakdown of fetomaternal blood barrier during labor might result in release of AFP or FFN into maternal serum. Maternal serum alpha fetoprotein and fetal fibronectin levels were measured prospectively in 29 patients in active labor at term and in 25 controls undergoing elective cesarean section. Neither MSAFP nor serum FFN levels were associated with labor at term. We did, however, note significantly higher MSAFP levels in mothers bearing male fetuses versus female fetuses (p < 0.01). Since the current literature supports a sex difference in the MSAFP levels in the second trimester, this does not appear to change as gestation advances. Further studies are needed to determine if, in addition to maternal weight and race, MSAFP levels should be also adjusted for fetal sex diagnosed on sonography.

In vitro evaluation of the pneumocandin antifungal agent L-733560, a new water-soluble hybrid of L-705589 and L-731373

Lipopeptide L-733560 is a hybrid analog of L-731373 and L-705589. All are water-soluble semisynthetic pneumocandin Bo derivatives. In vitro susceptibility testing of L-705589, L-731373, and L-733560 against more than 200 clinical isolates consisting of eight Candida species, Cryptococcus neoformans, and three Aspergillus species was performed by the broth microdilution methods. All three pneumocandins exhibited potent anti-Candida activity and moderate anti-C. neoformans activity. However, anti-Aspergillus activity was demonstrated only by an agar disk diffusion method. Antifungal agent-resistant Candida species and C. neoformans showed susceptibility comparable to that of susceptible isolates. Growth inhibition kinetic studies against Candida albicans revealed fungicidal activity within 3 to 5 h. Drug combination studies with pneumocandins and amphotericin B revealed indifferent activity against C. albicans and additive effects against C. neoformans and Aspergillus fumigatus. The activities of the compounds were not dramatically affected by the presence of serum. Resistance induction studies showed that the susceptibility of C. albicans MY1055 was not significantly altered by repeated exposure to subinhibitory concentrations of L-733560. Erythrocyte hemolysis studies indicated minimal hemolytic potential with pneumocandins. Results from preclinical evaluations and development studies performed thus far indicate that the pneumocandins should be safe, broad-spectrum fungicidal agents and potent parenteral antifungal agents.

The effect of multifetal pregnancy reduction on serum relaxin

OBJECTIVE

To determine the effect of multifetal pregnancy reduction on circulating relaxin levels.

METHODS

Patients with multifetal pregnancies had relaxin levels determined on the day of multifetal pregnancy reduction, after the procedure, and late in pregnancy.

RESULTS

Forty-eight women (26 presenting with three fetuses and 22 with four or more) were studied. All pregnancies followed some form of ovulation induction. All pregnancies (except for one, which was reduced to a singleton) were reduced to twins. Pre-procedure, post-procedure and late-pregnancy relaxin levels were significantly higher in the in vitro fertilization (IVF)-gamete intrafallopian transfer (GIFT) group compared with the human menopausal gonadotropin (hMG)-alone group (P < .05). The initial number of fetuses had no significant effect on relaxin levels. Although post-procedure relaxin levels were significantly lower than pre-procedure levels (P = .002), relaxin levels continued to decrease throughout pregnancy, as evidenced by even lower levels later on (P = .0001).

CONCLUSIONS

Serum relaxin levels were significantly higher in the IVF-GIFT group than in the hMG-alone group, which probably reflects more aggressive ovulation induction in the former. Because relaxin levels continued to decrease throughout pregnancy, the difference observed between pre- and post-procedure levels are not considered to be due to the procedure itself.

Alloimmune thrombocytopenia: fetal and neonatal losses related to cordocentesis

OBJECTIVE

This report describes the increased risks of cordocentesis in fetuses affected with alloimmune thrombocytopenia.

STUDY DESIGN

As part of a multicenter treatment study clinical and laboratory data from five pregnancies with alloimmune thrombocytopenia in which there was a fetal or neonatal loss associated with cordocentesis were reviewed. The fetal or neonatal deaths were all thought to be a result of exsanguination. These fetuses were compared with a group of 44 affected fetuses who underwent the same procedure but who survived. The data were analyzed by the Wilcoxon rank-sum test and the two-tailed Fisher's exact test. A p value < 0.05 was considered significant.

RESULTS

The mean platelet count at cordocentesis was significantly lower in the cases than in the controls (5.8 vs 32.8 x 10(9)/L, p = 0.005). The incidence of antenatal intracranial hemorrhage in the untreated sibling of the prior affected pregnancy was significantly greater in the cases than in the controls (two of five vs one of 42, p = 0.02).

CONCLUSION

Fetuses affected with alloimmune thrombocytopenia are at increased risk for fatal exsanguination associated with cordocentesis.

First-trimester multifetal pregnancy reduction: acute and persistent psychologic reactions

OBJECTIVE

Our purpose was to determine acute and persistent psychologic impacts of multifetal pregnancy reductions and patients' ability to cope with fetal loss while simultaneously bonding to surviving infants.

STUDY DESIGN

The first 100 women to undergo a multifetal reduction were invited to participate in a retrospective telephone study assessing their emotional reactions and attitudes toward multifetal reduction. The semistructured interview elicited demographic and obstetric data and contained scales used in previous studies of reproductive loss, which assessed repetitive thoughts about reduced fetuses, catastrophic fears, and lingering depressive feelings.

RESULTS

More than 65% of the sample recalled acute feelings of emotional pain, stress, and fear during the reduction procedure. Mourning for the lost fetuses was reported by 70% of women, but most grieved for only 1 month. Thoughts about reduced fetuses occurred moderately frequently after the reduction but rarely at follow-up. Persistent depressive symptoms were mild, although moderately severe levels of sadness and guilt continued for many. Nonetheless, 93% would make the same decision again. Emotional reactions of patients who miscarried differed little. The small subsample who continued to be most affected were younger (p < 0.02), were more religious (p < 0.003), and had viewed the multifetal pregnancy on ultrasonography more often (p < 0.009).

CONCLUSIONS

Multifetal reductions, although highly stressful psychologically, are well tolerated. Sadness and guilt may persist, especially for an identifiable subgroup. Normal maternal bonding and achievement of parenthood goals facilitate grief resolution. The large majority were reconciled to the termination of some fetuses to perserve the lives of a remaining few.

Evaluations of children who have disclosed sexual abuse via facilitated communication

OBJECTIVE

To review the findings of interdisciplinary team evaluations of children who disclosed sexual abuse via facilitated communication.

DESIGN

Case series.

SETTING

Tertiary care hospital outpatient child sexual abuse program in central New York.

PATIENTS

Between January 1990 and March 1993, 13 children who disclosed sexual abuse via facilitated communication and were referred to a university hospital child abuse referral and evaluation center. The range of previously determined developmental diagnosis included mental retardation, speech delay, and autism.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Medical records were reviewed for (1) disclosure, (2) physical evidence, (3) child's behavioral and medical history, (4) disclosures by siblings, (5) perpetrator's confession, (6) child protective services determinations, and (7) court findings.

RESULTS

Four children had evidence of sexual abuse: two had physical findings consistent with sexual abuse, one also disclosed the allegation verbally, and one perpetrator confessed.

CONCLUSIONS

These results neither support nor refute validation of facilitated communication. However, many children had other evidence of sexual abuse, suggesting that each child's case should be evaluated without bias.