Retrospective study evaluating the performance of a first-trimester combined screening for trisomy 21 in an Italian unselected population

OBJECTIVES

to assess the performance of a combined first-trimester screening for trisomy 21 in an unselected Italian population referred to a specialized private center for prenatal medicine.

METHODS

a retrospective validation of first-trimester screening algorithms [risk calculation based on maternal age and nuchal translucency (NT) alone, maternal age and serum parameters (free β-hCG and PAPP-A) alone and a combination of both] for fetal aneuploidies evaluated in an unselected Italian population at Artemisia Fetal-Maternal Medical Centre in Rome. All measurements were performed between 11(+0) and 13(+6) weeks of gestation, between April 2007 and December 2008.

RESULTS

of 3,610 single fetuses included in the study, we had a complete follow-up on 2,984. Fourteen of 17 cases of trisomy 21 were detected when a cut-off of 1:300 was applied [detection rate (DR) 82.4%, 95% confidence interval (CI) 64.2-100; false-positive rate (FPR) 4.7%, 95% CI 3.9-5.4; false-negative rate (FNR) 17.6%, 95% CI 0-35.8%].

CONCLUSION

in our study population the detection rate for trisomy 21, using the combined risk calculation based on maternal age, fetal NT, maternal PAPP-A and free β-hCG levels, was superior to the application of either parameter alone. The algorithm has been validated for first trimester screening in the Italian population.

Factors influencing choice of surgical route of repair of genitourinary fistula, and the influence of route of repair on surgical outcomes: findings from a prospective cohort study

OBJECTIVE

The abdominal route of genitourinary fistula repair may be associated with longer term hospitalisation, hospital-associated infection and increased resource requirements. We examined: (1) the factors influencing the route of repair; (2) the influence of the route of repair on fistula closure 3 months following surgery; and (3) whether the influence of the route of repair on repair outcome varied by whether or not women met the published indications for abdominal repair.

DESIGN

Prospective cohort study.

SETTING

Eleven health facilities in sub-Saharan Africa and Asia.

POPULATION

The 1274 women with genitourinary fistula presenting for surgical repair services.

METHODS

Risk ratios (RRs) and 95% confidence intervals (95% CIs) were generated using log-binomial and Poisson (log-link) regression. Multivariable regression and propensity score matching were employed to adjust for confounding.

MAIN OUTCOME MEASURES

Abdominal route of repair and fistula closure at 3 months following fistula repair surgery.

RESULTS

Published indications for abdominal route of repair (extensive scarring or tissue loss, genital infibulation, ureteric involvement, trigonal, supratrigonal, vesico-uterine or intracervical location or other abdominal pathology) predicted the abdominal route [adjusted risk ratio (ARR), 15.56; 95% CI, 2.12-114.00]. A vaginal route of repair was associated with increased risk of failed closure (ARR, 1.41; 95% CI, 1.05-1.88); stratified analyses suggested elevated risk among women meeting indications for the abdominal route.

CONCLUSIONS

Additional studies powered to test effect modification hypotheses are warranted to confirm whether the abdominal route of repair is beneficial for certain women.

The use of DHPLC (Denaturing High Performance Liquid Chromatography) in II level screening of the CFTR gene in Prenatal Diagnosis

OBJECTIVE

The aim of the study is to evaluate the role of Denaturing High Performance Liquid Chromatography (DHPLC) in the second level screening of the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene.

METHODS

A 9-month prospective study, between June 2008 and March 2009 at Artemisia Fetal Medical Centre, included 3829 samples of amniotic fluid collected from women undergoing mid-trimester amniocentesis.The genetic diagnosis of CF was based on research of the main mutations of the CFTR gene on fetal DNA extracted from the amniocytes, (first level screening) using different commercial diagnostic systems. A second level screening using DHPLC, on the amniotic fluid and on a blood sample from the couple, was offered in case of fetuses heterozygous at first level screening.

RESULTS

Of 3829 fetuses, 134 were found to be positive, 129 heterozygous and 5 affected. Of the 129 couples, following appropriate genetic counselling, 53 requested a second level screening. Through the use of DHPLC, 44 couples were found to be negative, and in nine couples, nine rare mutations were identified.

CONCLUSIONS

The first level screening can be useful to evidence up to 75% of the CF mutations. The second level screening can identify a further 10% of mutant alleles. DHPLC was found to be a reliable and specific method for the rapid identification of the rare CFTR mutations which were not revealed in initial first level screening.

Prenatal screening of Cystic Fibrosis: a single centre experience

OBJECTIVE

The gene responsible for the pathogenesis of cystic fibrosis has been known for over 15 years and represent the most common autosomal recessive disease in the european population. We aimed to investigate the incidence of this condition during fetal life.

METHODS

In the past 10 years we examined in our centre 25393 fetuses of women underwent to amniocentesis. We carried out the examination of the most frequent mutations which enable, according to the literature data, the identification of almost 80% of the affected alleles.

RESULT

We identified 922 heterozygous and 9 homozygous for the mutation. The frequency of heterozygousin the examined sample was 1/27,5 while that of the affected was 1/2821.

CONCLUSION

We encourage new thoughts regarding the diagnostic validity of the most frequent panel of mutations among the italian population in order to exclude never encountered mutations and the insertion of other more significant mutations.

Efficacy of percutaneous vas occlusion compared with conventional vasectomy

OBJECTIVES

To determine the efficacy, evaluate the safety and assess side-effects (swelling, haematoma and pain) of percutaneous vas occlusion compared with vasectomy in Dutch men.

PATIENTS AND METHODS

Vas occlusion and vasectomy procedures (attempted in 58 and 50 men, respectively) were conducted at the University Hospital Maastricht. The men returned 1 week after the procedure, underwent a clinical examination and completed a questionnaire assessing subjectively any pain, swelling and haematoma. The men were asked to return for semen analysis at 6 and 12 weeks and, if necessary, for additional analyses until they were azoospermic.

RESULTS

The vas occlusion procedure was completed on both vasa in 49 of the 58 men (84%) in whom it was attempted. Significantly more (P < 0.001) men were azoospermic after vasectomy (48 of 50) than after vas occlusion (only four). Men undergoing vas occlusion reported significantly less pain (P = 0.02), swelling (P = 0.01) and haematoma (P = 0.04) after the procedure than did men undergoing vasectomy.

CONCLUSION

Men undergoing vas occlusion would not have been able to rely on the method for contraception. From this study, vas occlusion, at least in its current form, is an unsuitable method of male contraception. Not only was the efficacy poor, but constraints in delivering the method in its current state would probably limit its utility, especially in situations where resources are limited.

UTI: diagnosis and evaluation in symptomatic pediatric patients

We retrospectively reviewed data on 260 hospitalized pediatric patients with symptomatic urinary tract infection (UTI). To ascertain the colony-forming units (CFU)/mL compatible with the diagnosis of UTI, a culture from a catheterized urine specimen containing >1,000 CFU/mL was considered diagnostic of UTI and resulted in imaging by renal ultrasound, voiding cystourethrography, and renal nuclear scan with Tc99m dimercaptosuccinic acid (DMSA). A positive DMSA renal scan is indicative of pyelonephritis. We used logistic regression analysis to determine which patient characteristics were predictive of pyelonephritis. We determined that, in hospitalized pediatric patients, the colony count of the positive urine culture, the type of organism grown in culture, and the voiding cystourethrography (VCUG) result (positive or negative for vesicoureteral reflux) did not predict which patients had pyelonephritis. In females, advancing age of the patient and positive renal ultrasound results were predictive of which patients had pyelonephritis when we controlled for other factors. We feel this emphasizes the importance of a thorough evaluation of hospitalized symptomatic patients, including patients with colony counts of 1,000 to 50,000 CFU/mL, to locate the level of infection and plan appropriate therapy.

Results of a pilot study of the time to azoospermia after vasectomy in Mexico City

In a joint pilot study by Family Health International (FHI), AVSC International, and the Instituto Mexicano del Seguro Social (IMSS), information was gathered on the determinants of azoospermia following vasectomy on 38 healthy men who chose vasectomy for contraception. The time and number of ejaculations associated with loss of sperm motility and loss of sperm eosin vital staining were also evaluated. "Azoospermia" was defined on the basis of two consecutive azoospermic semen samples collected at least 3 days apart. The single decrement life table method was used to calculate weekly gross cumulative life table rates for the time to azoospermia, zero motility, and zero viability. The Kaplan-Meier method was used to calculate the product-limit estimates of the cumulative rates for the total number of ejaculations to azoospermia, 0% motility and 0% viability. The median time to azoospermia was 10 weeks and at the end of week 20, the life table rate (+/- standard error) was 93.0 (+/- 6.30) weeks/100 men. The median number of ejaculations to azoospermia was between 25 and 30, and the cumulative rate (+/- standard error) at 60 ejaculations reached 94.5 (+/- 5.16)/100 men.

Adaptation and validation of a portable steam sterilizer for processing intrauterine device insertion instruments and supplies in low-resource settings

BACKGROUND

Difficulties with adequately processing intrauterine device (IUD) insertion instruments and supplies have led to use of potentially contaminated items, compromising the quality and safety of IUD insertion services in Bangladesh. A sterilization process for IUD insertion instruments and supplies by using a commercially available portable steam sterilizer was developed and validated.

METHODS

Racks provided with the sterilizer were used during sterilization of wrapped supplies (gloves and cotton balls). Metal compartments to hold insertion instruments were built to fit into the sterilizer. After sterilization, supplies were transported to rural service sites in plastic bags, whereas instruments remained in the sterilizer, which was transported in a carrying case. To validate the sterilizer, laboratory testing was conducted by using chemical and biologic indicators for steam sterilization and field testing in Bangladesh with chemical indicators.

RESULTS

Results indicated that sterilization cycles were effective in achieving sterility of IUD insertion supplies and instruments at sterility assurance levels of 10(-5) and 10(-6), respectively.

CONCLUSIONS

Use of this sterilizer for IUD insertion supplies and instruments will improve the quality of service delivery in the Bangladesh family-planning program and has application for use in many other low-resource settings.

A comparison of "U" and standard techniques for Norplant removal

OBJECTIVE

To evaluate the "U" technique versus the manufacturer-recommended technique for Norplant removal.

METHODS

We conducted a randomized comparison of the manufacturer-recommended method of removal and the "U" technique. The latter involves an incision between and parallel to the third and fourth implants and uses a modified vasectomy clamp to remove the implants by pulling perpendicular to the implant's axis.

RESULTS

Twenty-one physicians (three experienced, 18 inexperienced) performed 200 Norplant removals. Inexperienced physicians took significantly less time for removal using the "U" technique than the standard technique (7.9 versus 10.5 minutes), even after controlling for other factors. Experienced physicians also required less time for removal using the "U" technique (3.1 versus 3.7 minutes), but the difference was not statistically significant after controlling for other factors. Both experienced and inexperienced physicians broke implants more frequently using the standard technique, although the difference was significant only for experienced physicians (relative risk 3.6, 95% confidence interval 1.2, 10.8). No differences were noted between the techniques with respect to tissue damage or patient reports of pain during or after removal.

CONCLUSIONS

These results suggest that the "U" technique is an improvement over the standard technique, particularly for personnel who are not highly experienced in Norplant removal.

Mental illness and substance use among sheltered homeless persons in lower-density population areas

OBJECTIVE

The prevalence of mental illness and substance abuse in homeless populations has been studied primarily in large urban areas. This study examines a sheltered homeless population in two counties of lower-density population, Dauphin and Cumberland counties in central Pennsylvania, to assess the prevalence of mental illness and substance abuse.

METHODS

A total of 81 homeless adults from nine emergency shelters were interviewed using a structured questionnaire.

RESULTS

The estimated lifetime prevalence rate of major depressive disorder was 26.6 percent; 6.4 percent of the sample showed evidence of psychotic thinking. Almost one-third reported previous hospitalization for emotional problems, and about one-third reported a suicide attempt. The estimated lifetime prevalence rate of alcohol or drug abuse or dependence was almost 60 percent.

CONCLUSIONS

Although mental illness, especially psychosis, and substance abuse may be somewhat less prevalent among homeless persons in lower-density population areas than in large urban areas, they are nevertheless significant problems.

Gonadotrophin dose and timing of anaesthesia for laparoscopic artificial insemination in the puma (Felis concolor)

Ovarian response to equine chorionic gonadotrophin (eCG) and human chorionic gonadotrophin (hCG), the effect of timing of anaesthesia relative to hCG injection and the use of laparoscopic intrauterine artificial insemination were examined in the puma (Felis concolor). In Expt 1, females were treated with 100 (n = 6) or 200 (n = 8) IU eCG (i.m.) followed 80 h later by 100 IU hCG (i.m.) and were then anaesthetized 40-43 h after hCG injection for ovarian assessment. Although there was no difference (P > 0.05) in the number of unovulated ovarian follicles, females treated with 200 IU eCG had more (P < 0.05) corpora lutea per female and more corpora lutea as a percentage of the total number of ovarian structures. In Expt 2, all females were treated with 200 IU eCG and 80 h later with 100 IU hCG, and then anaesthetized either 31-39 h (Group A; n = 8) or 41-50 h (Group B; n = 6) after hCG injection for ovarian assessment. All Group B pumas ovulated compared with only three (37.5%) Group A females (P < 0.05). Compared with Group A, Group B pumas had more corpora lutea per female, more corpora lutea as a percentage of the total number of ovarian structures, and fewer unovulated follicles (P < 0.05). One of nine post-ovulatory females laparoscopically inseminated in utero with 16 x 10(6) motile spermatozoa became pregnant and delivered a healthy cub.(ABSTRACT TRUNCATED AT 250 WORDS)

Mature domestic cat oocyte does not express a cortical granule-free domain

A premature release of cortical granules (CG), found in the cortex of unfertilized oocytes, and the resulting formation of a CG-free domain (CGFD) over the metaphase II spindle are associated with nuclear maturation in the hamster and mouse. The objectives of our study were to characterize and compare the distribution of CG in immature, in vitro-matured, and in vivo-matured domestic cat oocytes while determining if a CGFD is formed that may be useful as a marker for stage and normalcy of oocyte maturation. Immature, intrafollicular oocytes were collected from ovaries obtained from local veterinary clinics, and a portion of these oocytes were matured in vitro. In vivo-matured, metaphase II oocytes were flushed from the oviducts of gonadotropin-treated, ovariohysterectomized cats. CG were visualized by Lens culinaris agglutinin-biotin/Texas red-strepavidin fluorescence, routine transmission electron microscopy, and Lens culinaris agglutinin-biotin/gold-labeled strepavidin transmission electron microscopy. No CGFD was detected in any domestic cat oocyte. Immature, in vitro-matured, and in vivo-matured oocytes had similar, uniform distributions of CG throughout the entire cortical region as measured by fluorescence microscopy. In vivo-matured oocytes were further examined by transmission electron microscopy, which confirmed the lack of a CGFD. All oocytes contained CG having a mean diameter of 0.28 +/- 0.03 micron/granule and a mean density of 51.5 +/- 13.0 CG/100 microns of plasma membrane.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of pre-ovulatory anaesthesia on ovulation in laparoscopically inseminated domestic cats

Laparoscopic intrauterine artificial insemination (AI) of electroejaculated spermatozoa was used to compare embryo development and conception rates in domestic cats inseminated either before or after ovulation. Females were given a single (100 iu) injection of pregnant mares' serum gonadotrophin (PMSG) followed by either 75 or 100 iu human chorionic gonadotrophin (hCG) 80 h later. Cats were anaesthetized (injectable ketamine HCl/acepromazine plus gaseous halothane) 25-50 h after administration of hCG for laparoscopic assessment of ovarian activity and for transabdominal AI into the proximal aspect of the uterine lumen. At the time of AI, 23 cats were pre-ovulatory (25-33 h after hCG injection) and 30 were post-ovulatory (31-50 h after hCG injection). Pre-ovulatory females produced 10.5 +/- 1.1 follicles and no corpora lutea compared with 1.9 +/- 0.5 follicles and 7.5 +/- 0.9 corpora lutea for the post-ovulatory group (P < 0.05). Six days later, the ovaries of nine pre-ovulatory and 12 post-ovulatory females were re-examined and the reproductive tracts flushed. On this day, pre-ovulatory cats produced fewer corpora lutea (2.8 +/- 1.5; P < 0.05) and embryos (0.4 +/- 0.3; P < 0.05) than post-ovulatory females (18.9 +/- 3.3 corpora lutea; 4.6 +/- 1.2 embryos). Two of the 14 cats (14.3%) inseminated before ovulation and not flushed became pregnant compared with 9 of 18 cats (50.0%) inseminated after ovulation and up to 41 h after hCG injection (P < 0.05). These results indicate that ovulation in cats is compromised by pre-ovulatory ketamine HCl/acepromazine/halothane or laparoscopy or by both and that electroejaculated spermatozoa deposited by laparoscopy in utero, after ovulation, result in a relatively high incidence of pregnancy. Because ovulation usually occurs 25-27 h after injection of hCG, the lifespan for fertilization of the ovulated ovum appears to be at least 14 h in vivo in cats.