Expert consensus on neurodevelopmental outcomes in pregnancy pharmacovigilance studies

Background: Exposure in utero to certain medications can disrupt processes of fetal development, including brain development, leading to a continuum of neurodevelopmental difficulties. Recognizing the deficiency of neurodevelopmental investigations within pregnancy pharmacovigilance, an international Neurodevelopmental Expert Working Group was convened to achieve consensus regarding the core neurodevelopmental outcomes, optimization of methodological approaches and barriers to conducting pregnancy pharmacovigilance studies with neurodevelopmental outcomes. Methods: A modified Delphi study was undertaken based on stakeholder and expert input. Stakeholders (patient, pharmaceutical, academic and regulatory) were invited to define topics, pertaining to neurodevelopmental investigations in medication-exposed pregnancies. Experts were identified for their experience regarding neurodevelopmental outcomes following medicinal, substances of misuse or environmental exposures in utero. Two questionnaire rounds and a virtual discussion meeting were used to explore expert opinion on the topics identified by the stakeholders. Results: Twenty-five experts, from 13 countries and professionally diverse backgrounds took part in the development of 11 recommendations. The recommendations focus on the importance of neurodevelopment as a core feature of pregnancy pharmacovigilance, the timing of study initiation and a core set of distinct but interrelated neurodevelopmental skills or diagnoses which require investigation. Studies should start in infancy with an extended period of investigation into adolescence, with more frequent sampling during rapid periods of development. Additionally, recommendations are made regarding optimal approach to neurodevelopmental outcome measurement, comparator groups, exposure factors, a core set of confounding and mediating variables, attrition, reporting of results and the required improvements in funding for potential later emerging effects. Different study designs will be required depending on the specific neurodevelopmental outcome type under investigation and whether the medicine in question is newly approved or already in widespread use. Conclusion: An improved focus on neurodevelopmental outcomes is required within pregnancy pharmacovigilance. These expert recommendations should be met across a complementary set of studies which converge to form a comprehensive set of evidence regarding neurodevelopmental outcomes in pregnancy pharmacovigilance.

Long-term follow-up of patients >or=60 yr old with acute myeloid leukaemia treated with intensive chemotherapy

It is still controversial how to treat elderly patients with acute myeloid leukaemia (AML), and results have been poor with most regimens. We report the long-term results of a randomised study performed by the Leukaemia Group of Middle Sweden during 1984-88 comparing two intensive chemotherapeutic drug combinations. Ninety patients >or=60-yr old with untreated AML were randomly allocated to treatment with daunorubicin, cytosine arabinoside (ara-C), and thioguanine (TAD) (43 patients) or a combination in which aclarubicin was substituted for daunorubicin (TAA) (47 patients). Forty-four patients (49%) entered complete remission (CR), 22/43 (51%) in the TAD group and 22/47 (47%) in the TAA group (ns). The CR rate in patients <or=70 yr of age was 30/42 (71%) and in patients >70 yr 14/48 (29%) (P<0.0001). Early death within 30 d after treatment initiation was more often seen in patients >70 yr than in patients <or=70 yr of age, 40% and 12%, respectively (P<0.005). The median cause-specific survival time was 178 d in the total patient group, and the 2-, 5-, and 10-yr survivals were 22%, 11%, and 8%, respectively. The cause-specific survival was not significantly different between the two treatment arms. At long-term follow-up >or=10 yr after inclusion of the last patient, 5/90 patients (one in the TAD group and four in the TAA group, respectively) were still alive, four in continuous complete remission and one in second complete remission. Thus, both treatment regimens appear to have similar efficacy, with a relatively high complete remission rate, and a reasonable survival as compared to other studies including some long-term survivors. However, early deaths are still numerous, particularly in patients above 70 yr of age, and the relapse rate is substantial.

Biopsy protocol stability in a three-dimensional model of prostate cancer: changes in cancer yield after adjustment of biopsy positions

OBJECTIVES

Transrectal ultrasound-guided prostate biopsies are often taken according to a systematic, standardized schedule. The diagnostic stability of this system was evaluated by moving the biopsies in a three-dimensional (3D) model.

METHODS

A computerized 3D reconstruction was made from each of 75 radical prostatectomy specimens. Simulated core biopsies imitated a standardized 10-biopsy protocol, including sextant biopsies. In total, 30,000 biopsies were generated by moving the standardized biopsies 1, 2, 3, and 4 mm (parallel needle shifts) or 5 degrees, 10 degrees, 15 degrees, and 20 degrees(rotation of the needle tip) in a random direction.

RESULTS

The diagnosis of the individual biopsy changed from cancer to benign or vice versa in 4.9% to 1 5.7% after 1 to 4-mm parallel needle shifts and 2.0% to 7.5% after 5 degrees to 20 degrees rotations. The corresponding figures for the final diagnosis of the 10-biopsy set were 0.8% to 9.6% and 0.5% to 3.2%. Transition zone biopsies containing cancer changed to benign more often than the other biopsies (P <0.001). Parallel needle shifts of 2 mm changed the diagnosis more often than the 15 degrees rotation (9.4% and 5.9%, respectively, P <0.001), although conveying the same overall needle shift.

CONCLUSIONS

The cancer yield of prostate biopsies is influenced even by small changes in needle positions. The transition zone biopsies are most likely to change from cancer to benign when moved. Changing the insertion point of the needle has a higher impact on cancer yield than rotating the tip.

Battering in pregnant Latinas

Evidence suggests that abuse of women may be the most common form of family violence during the perinatal period. This battering is associated with adverse pregnancy outcomes and has physical, psychological, and social sequelae. Although some ethnic differences have been described in the occurrence of abuse, there is a paucity of research and culturally relevant prevention strategies and interventions to assist minority women. With both quantitative and qualitative methods, this study examined pregnant Latinas in three sites: urban Arizona, rural Arizona, and Mexico, to determine prevalence and type of abuse, level of acculturation, and self-esteem. Women were approached by a bilingual research assistant until 150 from each site agreed to participate. After informed consent was obtained, the questionnaires were administered in English or Spanish and read orally if the participant was unable to read. Focus groups with women recruited from each site by means of a return mail postcard provided qualitative information regarding their perceptions of battering, available resources, and how the Mexican culture influences this phenomenon. The women in the rural Arizona site reported the highest incidence of abuse and the highest levels of acculturation. Women in the focus groups discussed cultural reasons for violence and described helpful measures that could be offered to abused women.

Three-dimensional computer reconstruction of prostate cancer from radical prostatectomy specimens: evaluation of the model by core biopsy simulation

OBJECTIVES

A technique was developed for three-dimensional (3D) modeling of prostate cancer and transrectal biopsies. To test the model, the cancer yield of a simulated 10-biopsy protocol was compared with a simulated sextant protocol and with preoperative biopsies regarding cancer detection and correlation with tumor volume.

METHODS

Transrectal ultrasound-guided core biopsies were taken from 81 men according to a standardized 10-biopsy protocol that included sextant biopsies. The patients underwent radical prostatectomy and specimens were step-sectioned and whole-mounted. Cancer and the prostate capsule were outlined on the slides and the regions transferred to a computer software program developed by our group. A 3D volume of each prostate was reconstructed from the sections. Virtual core biopsy needles imitating the positions of the real biopsies were inserted into the prostate and the cancer yield was calculated. Only the standardized positions were considered in this study (ie, additional biopsies from hypoechoic foci were not accounted for).

RESULTS

Of the cancers detected with 10 standardized virtual biopsies, 24% would have remained undetected with sextant biopsies. The cancer yield of 10 virtual biopsies correlated with the preoperative biopsies (r = 0.64) and with the tumor volume (r = 0.56). A multiple regression analysis showed that the cancer yield of a simulation of 10 biopsies correlated better with tumor volume than did a simulation of sextant biopsies (P = 0.02).

CONCLUSIONS

We conclude that computer-assisted 3D reconstruction of prostate cancer can be used as a model for evaluation and optimization of biopsy protocols.

Seroprevalence of human granulocytic ehrlichiosis among permanent residents of northwestern Wisconsin

Four-hundred seventy-five permanent residents of Wisconsin were tested for antibodies to the agent of human granulocytic ehrlichiosis (HGE) by indirect immunofluorescent antibody (IFA) testing with Ehrlichia equi as antigen marker. Each resident completed a standard survey questionnaire about outdoor activities, animal and tick exposure, and any febrile illness during the preceding 12 months. Seventy-one serum samples (14.9%) contained E. equi antibodies. The mean IFA titer for seropositive residents was 250 (range, 80-10,240). Seropositive residents were older than seronegative ones (62 vs. 56 years; P = .019). None of the seropositive residents had a history suggestive of ehrlichiosis. There was no association between the IFA test outcome and specific demographic variables or history of tick bites. HGE appears to be a common subclinical or mild infection among residents in northwestern Wisconsin.

Estimation of prostate cancer volume by multiple core biopsies before radical prostatectomy

OBJECTIVES

To investigate whether tumor volume, an important prognostic factor in prostate cancer, could be estimated from the amount of cancer in multiple core biopsies.

METHODS

In 80 men, transrectal ultrasound-guided biopsies were taken from focal lesions detected by ultrasound and 8 to 10 standardized positions, including sextant biopsies (apex, midmedial, base) and midlateral and transition zone biopsies. The cancer length in the biopsies was measured. After radical prostatectomy, the prostates were totally embedded, whole-mounted, and tumor volume was measured planimetrically.

RESULTS

The tumor volume correlated significantly with the total cancer length of all biopsies (r = 0.56) and of the sextant biopsies (r = 0.39). It was found that midlateral and transition zone biopsies provided independent information when included in a multiple regression model with tumor volume as the dependent variable and the sextant biopsies as explanatory variables. All men (n = 6) with less than 3 mm cancer length in only one positive biopsy and a Gleason score less than 7 had a tumor volume less than 1 mL. Nine of 10 men with less than 7 mm of cancer in one positive biopsy and Gleason score less than 7 had tumors smaller than 1 mL. Sextant biopsies did not reliably predict cancer volumes less than 1 mL.

CONCLUSIONS

The cancer yield of 8 to 10 biopsies correlated better with the volume of prostate cancer than sextant biopsies. This extended biopsy protocol could be used to predict cancers of less than 1 mL in volume.

Body protein as a prognostic instrument for cancer patients?

Many cancer patients are affected by loss of appetite, weight loss and fatigue in the course of disease. These symptoms reduce the patients' quality of life, increase morbidity, and lessen tolerance to anti-tumor treatment. In some cases the symptoms are partly caused by various treatment modalities. The aim of this study was to investigate if radiotherapy affects the body weight and body protein of patients, and if changes in body protein have any clinical significance.

Maternal-child health in Zimbabwe

In this paper I describe maternal and child health needs in Zimbabwe, as well as existing health care delivery services designed to meet these needs. The information presented is based on a project sponsored by Earthwatch (a worldwide volunteer organization) that addressed the needs of women and infants, as well as the author's contribution to this effort. Because of a long-standing drought, many women and children in Zimbabwe are malnourished. Poor nutrition affects the woman herself, pregnancy outcomes, and the developing child, and has far-reaching repercussions. The major problems that contribute to maternal child morbidity and mortality include nutritional deficiencies, lack of safe water, and family planning needs. Earlier surveys conducted on maternal nutrition consistently showed iron deficiency, goiters, underweight, and inadequate nutrient intake to be quite prevalent. On the basis of previous assessments, this project focused on educating community health workers on ways to assist families with nutritional deficiencies, family planning, and hygiene needs.

Morphometric studies of intra-prostatic volume relationships in localized prostatic cancer

OBJECTIVES

To further characterize patterns of tumour growth and the distribution of markers for the aggressiveness of prostate cancer by assessing the relationships among the volume of the 'index' tumour and that of the remaining foci, with pathological (pT) stage, histological grade and DNA ploidy, and with the amount of low- and high-grade prostatic intraepithelial neoplasia (PIN).

MATERIALS AND METHODS

Eighty-eight step-sectioned total prostatectomy specimens were analysed. The Gleason score, tumour stage and DNA ploidy (by flow cytometry) of multiple samples were determined. Tumour and PIN areas were outlined and their volumes estimated by computerized planimetry.

RESULTS

The pT stage, Gleason sum and DNA nondiploidy increased, and PIN volumes decreased, with increasing volume of the index tumour focus (P < 0.01), but did not differ significantly between uni- and multifocal tumours. However, PIN volumes were significantly larger in multifocal cases with an index tumour volume of > 3 mL than in unifocal tumours > 3 mL (P < 0.05). Small volume, unifocal tumours had little PIN. The most malignant features of each case were always represented in the index tumour but not generally in the remaining foci.

CONCLUSIONS

The volume distribution, related to multicentricity and its concomitant PIN volumes, indicates that large index tumours, uni- or multifocal, of medium or high grade, are associated with low PIN volumes. However, multifocal medium- and high-grade tumours with small index tumour volumes have higher PIN volumes. Small, single tumours are of low-grade and may represent the slowly progressing cancers possibly resembling those found in autopsy studies.

How to Generate Non-normal Data for Simulation of Structural Equation Models

A procedure for generating non-normal data for simulation of structural equation models is proposed. A simple transformation of univariate random variables is used for the generation of data on latent and error variables under some restrictions for the elements of the covariance matrices for these variables. Data on the observed variables is then computed from latent and error variables according to the model. It is shown that by controlling univariate skewness and kurtosis on pre-specified random latent and error variables, observed variables can be made to have a relatively wide range of univariate skewness and kurtosis characteristics according to the pre-specified model. Univariate distributions are used for the generation of data which enables a user to choose from a large number of different distributions. The use of the proposed procedure is illustrated for two different structural equation models and it is shown how PRELIS can be used to generate the data.

On the growth rates of human malignant tumors: implications for medical decision making

Testicular carcinomas, pediatric tumors, and some mesenchymal tumors are examples of rapidly proliferating cell populations, for which the tumor volume doubling time (TVDT) can be counted in days. Cancers from the breast, prostate, and colon are frequently slow-growing, displaying a TVDT of months or years. Irrespective of their growth rates, most human tumors have been found: to start from one single cell, to have a long subclinical period, to grow at constant rates for long periods of time, to start to metastasize often even before the primary is detected, and to have metastases that often grow at approximately the same rate as the primary tumor. The recognition of basic facts in tumor cell kinetics is essential in the evaluation of important present-day strategies in oncology. Among the facts emphasized in this review are: (1) Screening programs. Most tumors are several years old when detectable by present-day diagnostic methods. This makes the term "early detection" questionable. (2) Legal trials. The importance of so-called doctor's delay is often discussed, but the prognostic value of "early" detection is overestimated. (3) Analyses of clinical trials. Such analysis may be differentiated depending on the growth rates of the type of tumor studied. Furthermore, uncritical analysis of survival data may be misleading if the TVDT is not taken into consideration. (4) Analyses of epidemiological data. If causes of malignant tumors in humans are searched for, the time of exposure must be extended far back in the subject's history. (5) Risk estimations by insurance companies. For the majority of human cancers, the 5-year survival rate is not a valid measurement for cure. Thus, basic knowledge of tumor kinetics may have important implications for political health programs, legal trials, medical science, and insurance policies.

What is the long term value of multiphasic health screening and the initial judgement of benefit?

The long term effects of multiphasic health screening (MHS) are rarely studied. In 1964 a random sample of 546 women and 544 men born 1899, 1904, 1909, 1914 or 1919 equally distributed on cohorts from the Swedish town Eskilstuna were invited to examination. For several reasons 167 persons (15%) did not participate in the study. In 1969 the whole sample was invited to a second MHS together with a control group that had not been exposed to MHS. Furthermore, 79 of those alive 1989 born 1899 or 1904 and examined 1964 and 1969 were reexamined. Over all survival rate 1989 for those examined 1964 was for males 18% and for females 35%. Screening instruments 1964 and 1969 were questionnaires, laboratory tests, antropometric measurements, ECG, measurement of blood pressure, chest radiography, peak expiratory flow (PEF), tonometry and fundoscopy of the eyes, audiometric screening, dental, gynecological and general clinical examination. Systolic hypertension for both sexes, low PEF and smoking, low cholesterol in women were negatively related to survival. Of 18 diabetics only one was alive at follow-up. No association was found between BMI and mortality for men, but some (1964 p < 0.01; 1969 p < 0.05) for women. Altogether 87 individuals were 1969 judged to have had some benefit of the MHS in 1964, 40 of them substantial. This was, however, not statistically significantly associated with improved survival. Of the reexamined survivors 86% reported to be generally satisfied with their life situation. The prognostic value of graded benefit was analysed in some detail. The survival to age 85 in the group allotted any benefit was somewhat less good (37%) than in the group with no benefit (44%). The difference did not reach statistical significance.

A comparison of cathepsin D levels in endometriotic tissue and in uterine endometrium

OBJECTIVE

To assay the cathepsin D level in endometriotic tissue, to study the difference to uterine endometrium and the correlation to localization.

DESIGN

Prospective consecutive study on endometriotic tissue and endometrium.

SETTING

University clinic.

PATIENTS

Thirty-five women undergoing laparotomy for clinical indications.

INTERVENTIONS

Samples of endometriotic tissue and uterine endometrium were obtained simultaneously from the same woman at laparotomy, fresh frozen, and assayed using an immunoradiometric method.

MAIN OUTCOME MEASURE

The cathepsin D level in endometrium and endometriotic tissue expressed in pmol/mg DNA.

RESULTS

The cathepsin D level was significantly higher in endometriotic tissue than in endometrium both in follicular and luteal phase. The highest values in endometriotic tissue were found in luteal phase, in ovarian lesions, and in primary lesions. In endometrium, but not in endometriotic tissue, there was a positive correlation between cathepsin D level and serum E2 level.

CONCLUSION

The level of the proteolytic enzyme cathepsin D is significantly higher in endometriotic tissue than in endometrium, which might be of importance for implantation and the invasive growth of endometriotic tissue.

Delay in prenatal care as a result of battering in pregnancy: cross-cultural implications

White American, Hispanic, and African American women were surveyed in public health and low-income clinics in Los Angeles, California, and Seattle, Washington, to determine if they delayed seeking prenatal care because of battering during their pregnancies. Nursing staff in the clinics attempted to enroll in the study all pregnant women from these groups who presented themselves for care; no other criteria were used, other than the ability to read either English or Spanish. Results were obtained from 162 White Americans, 208 Hispanics, and 132 African Americans. Although the incidence of abuse was not significantly different among the ethnic groups, battered women sought prenatal care 6.5 weeks later than the nonabused sample, with a similar delay in each ethnic group. Twenty-one percent of the women reported physical harm during the pregnancy, and 13.7% stated that they had delayed care because of injuries.

Culturally sensitive perinatal care for southeast Asians

This article presents strategies for providing perinatal care to Southeast Asians living in the United States and Canada. The population is described, and attention is paid to how their past and continued lifestyle contribute to health problems. Traditional healing beliefs and practices, especially those pertaining to childbearing, are discussed. A demonstration project in Long Beach, California, is described as a model for delivering culturally sensitive care.

Mental health of Southeast Asian refugee women: an overview

Southeast Asian refugee women suffered extremely traumatic experiences at the hands of the Khmer Rouge, during their escapes from Cambodia and Laos, and in refugee camps. I describe these experiences as the background for interventions to promote and re-establish mental health in these women. A reported study of women who were experiencing psychosomatic blindness as a result of the trauma they had undergone is presented as an example. Therapeutic strategies are suggested.

Culturally sensitive prenatal care for Southeast Asians

OBJECTIVE

To evaluate the success of the Southeast Asian Health Project in terms of client satisfaction with the prenatal care and other services. To obtain additional data about Southeast Asian women's health practices regarding childbearing.

DESIGN

Survey through questionnaires administered as interviews.

SETTING

In clients' homes or via telephone.

PARTICIPANTS

119 women from SEAHP's case files of recently delivered clients.

MEASUREMENTS AND MAIN RESULTS

Interviews were conducted by four community workers fluent in Cambodian or Lao. The majority of women were satisfied with SEAHP, particularly the interpretation and education in native languages. Women were also satisfied with SEAHP, encouraging others to seek care.

CONCLUSIONS

SEAHP appears to meet prenatal care needs of Southeast Asian women in Long Beach, California. More objective outcome data await analyses, but the program's approach may ensure access to and use of health services.

Prevalence of antibodies to Toxoplasma gondii in cats, dogs and horses in Sweden

Samples of serum or plasma taken during 1986 and 1987 from 244 pet cats, 303 dogs and 219 horses, randomly selected among animals referred to the Animal Clinics of the Swedish University of Agricultural Sciences, were screened by enzyme-linked immunosorbent assay (ELISA) for antibodies to Toxoplasma gondii. 42% of cats, 23% of dogs and 1% of horses examined were found seropositive.

Impaired alternation test performance in adult rats following prenatal alcohol exposure

The effects of prenatal exposure to ethanol on an alternation test were examined in adult Long Evans rats from three prenatal treatment groups: prenatal alcohol exposed (35% ethanol-derived calories, 35% EDC), nutritional control (0% ethanol-derived calories, 0% EDC) or standard control (lab chow, LC). Subjects were trained to alternate presses on levers to the left and right of a center food trough. Prenatal treatment did not affect the acquisition of this spatial alternation task. However, during the asymptotic performance phase of the task, subjects prenatally exposed to alcohol received fewer rewards and made more errors compared to the two control groups, which did not differ from each other. Even when test sessions were limited to 10 min, performance deficits in the 35% EDC group persisted. When visual cues were made available above the correct bar in a second experiment, performance deficits in alcohol-exposed subjects were no longer apparent. Marked sex differences were also noted in this task: males received more reinforcements, but also made more errors. Prenatal alcohol exposure may disrupt the normal development of behavioral laterality subserving position preferences, and this disruption may partly explain why performance of some spatial tasks is particularly sensitive to the effects of prenatal alcohol exposure.

Lead in vertebral bone biopsies from active and retired lead workers

Samples of vertebral bone were obtained by skeletal biopsy and lead concentrations were determined by atomic absorption spectroscopy. The median level of lead in bone in 27 active lead workers was 29 micrograms/g wet weight (range 2-155), corresponding to 370 micrograms/g calcium (range 30-1,120). In 9 retired workers, the corresponding levels were 19 micrograms/g (5-76) and 250 micrograms/g calcium (60-700); in 14 reference subjects without occupational exposure, 1.3 micrograms/g (1-4) and 13 micrograms/g calcium (8-40). The bone lead content rose with time of exposure. Comparison of levels in vertebra with those in fingerbone, as measured by in vivo x-ray fluorescence in the same subjects, strongly suggested the presence of lead pools with different kinetics. The accumulation pattern, as well as the relation between levels in vertebra and fingerbone, suggests a much shorter half-time of lead in the mainly trabecular vertebral bone as compared to the mainly cortical fingerbone. Further, there was an association between vertebral and blood lead levels in the retired workers, which shows a considerable endogenous lead exposure from the skeletal pool.

Whole body measurements of sodium turnover in offspring of patients with sustained essential hypertension

The elimination rate (percent per day) of injected 22Na using a whole body measurement technique was significantly lower (5.8 +/- 1.5) in normotensive or borderline hypertensive offspring of essential hypertensive patients than in 15 age- and sex-matched, normotensive controls (7.3 +/- 1.0). There were no significant differences in exchangeable sodium, whole body potassium or in the urinary excretion of sodium, potassium and creatinine. The basis for the difference in turnover rate during week 1 is probably an alteration in the cellular handling of sodium (i.e. increased intracellular sodium) in the still normotensive offspring of patients with essential hypertension. The long-term (more than 100 days) whole body retention of 22Na was found to be only 0.1% of that injected, which justifies the use of this method on larger population groups.