Impact of prenatal estimation of the risk of respiratory distress in neonates with congenital pulmonary malformations on the choice of delivery site

BACKGROUND

The vast majority of prenatally diagnosed congenital pulmonary malformations (CPM) remain asymptomatic at birth. The maximal value of the CPM volume ratio (CVRmax) predicts the risk of neonatal respiratory distress (NRD), and should allow for better assessment of the level of expertise needed at the delivery site.

AIM

This study evaluated the level of maternity units currently chosen for the delivery of CPMs, and determined the impact of the choice of delivery site based on the CVRmax, with a threshold of 0.4 cm².

METHODS

Data were extracted from the French prospective MALFPULM cohort, with inclusion between March 2015 and June 2018.

RESULTS

The final study population consisted of 383 women. Deliveries in level 1 or 2 maternity units (n = 98, 25%) involved CPMs with lower CVRmax (p<0.001), causing fewer signs of prenatal compression (p = 0.025). Among the 62 children (16%) who presented with NRD, only seven (11%) were born in level 1 or 2 units (p = 0.0078). Choosing the maternity level according to the CVRmax would have increased the number of births in level 1 or 2 maternity hospitals by 70%. In these maternity units, the percentage of children with NRD would have increased from 8% in the actual distribution to 10% in the new strategy.

CONCLUSION

Our results showed an overuse of level 3 maternity hospitals for the delivery of newborns with a prenatal diagnosis of CPM. The use of CVRmax should enable a reduction in the use of expertise centers without an adverse impact on newborns.

The importance of clinicians' and parents' awareness of suicidal behaviour in adolescents reaching the upper age limit of their mental health services in Europe

BACKGROUND

To study clinicians' and parents' awareness of suicidal behaviour in adolescents reaching the upper age limit of their Child and Adolescent Mental Health Service (CAMHS) and its association with mental health indicators, transition recommendations and mental health service (MHS) use.

METHODS

763 CAMHS users from eight European countries were assessed using multi-informant and standardised assessment tools at baseline and nine months follow-up. Separate ANCOVA's and pairwise comparisons were conducted to assess whether clinicians' and parents' awareness of young people's suicidal behaviour were associated with mental health indicators, clinician's recommendations to continue treatment and MHS use at nine months follow-up.

RESULTS

53.5 % of clinicians and 56.9 % of parents were unaware of young people's self-reported suicidal behaviour at baseline. Compared to those whose clinicians/parents were aware, unawareness was associated with a 72-80 % lower proportion of being recommended to continue treatment. Self-reported mental health problems at baseline were comparable for young people whose clinicians and parents were aware and unaware of suicidal behaviour. Clinicians' and parents' unawareness were not associated with MHS use at follow-up.

LIMITATIONS

Aspects of suicidal behaviour, such as suicide ideation, -plans and -attempts, could not be distinguished. Few young people transitioned to Adult Mental Health Services (AMHS), therefore power to study factors associated with AMHS use was limited.

CONCLUSION

Clinicians and parents are often unaware of suicidal behaviour, which decreases the likelihood of a recommendation to continue treatment, but does not seem to affect young people's MHS use or their mental health problems.

Lésions placentaires graves dues à une infection maternelle par le SARS-CoV-2 associées à une mort fœtale intra-utérine

L’infection par le SRAS-CoV-2 peut provoquer des lésions placentaires sévères conduisant rapidement à une mort fœtale intra-utérine (MFIU). Entre août 2020 et septembre 2021, nous avons reçu et analysé 50 placentas de mères non vaccinées positives au COVID-19, dans le service de pathologie de Toulouse.

Le but de notre étude est de décrire les caractéristiques clinicopathologiques de ces atteintes placentaires et d’en comprendre la physiopathologie.

Dix d’entre eux (20 %) présentaient des lésions placentaires avec une immunohistochimie positive au SARS-CoV-2 au niveau du trophoblaste villositaire. Dans cinq cas (10 %), nous avons observé des lésions placentaires massives associant nécrose trophoblastique, dépôts fibrinoides, intervillite ainsi que des modifications hémorragiques étendues dues à l’infection par le SARS-CoV-2 probablement responsable de la MFIU par insuffisance placentaire fonctionnelle. Dans cinq autres cas, nous avons trouvé des lésions placentaires similaires mais avec une distribution focale ayant conduit à une naissance vivante.

Ces lésions sont indépendantes de la sévérité clinique maternelle de l’infection à COVID-19 car elles surviennent malgré des symptômes maternels bénins les rendant difficiles à prévoir. Dans nos cas, elles sont apparues 1 à 3 semaines après un test RT-PCR maternel positif au SRAS-CoV-2 et ont été observées au cours des 2^e et 3^e trimestres de la grossesse. Lorsque ces lésions sont focales, elles n’entraînent pas de MFIU mais peuvent être associées à un retard de croissance intra-utérin.

Demographic, clinical, and service-use characteristics related to the clinician's recommendation to transition from child to adult mental health services

PURPOSE

The service configuration with distinct child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) may be a barrier to continuity of care. Because of a lack of transition policy, CAMHS clinicians have to decide whether and when a young person should transition to AMHS. This study describes which characteristics are associated with the clinicians' advice to continue treatment at AMHS.

METHODS

Demographic, family, clinical, treatment, and service-use characteristics of the MILESTONE cohort of 763 young people from 39 CAMHS in Europe were assessed using multi-informant and standardized assessment tools. Logistic mixed models were fitted to assess the relationship between these characteristics and clinicians' transition recommendations.

RESULTS

Young people with higher clinician-rated severity of psychopathology scores, with self- and parent-reported need for ongoing treatment, with lower everyday functional skills and without self-reported psychotic experiences were more likely to be recommended to continue treatment. Among those who had been recommended to continue treatment, young people who used psychotropic medication, who had been in CAMHS for more than a year, and for whom appropriate AMHS were available were more likely to be recommended to continue treatment at AMHS. Young people whose parents indicated a need for ongoing treatment were more likely to be recommended to stay in CAMHS.

CONCLUSION

Although the decision regarding continuity of treatment was mostly determined by a small set of clinical characteristics, the recommendation to continue treatment at AMHS was mostly affected by service-use related characteristics, such as the availability of appropriate services.

Cohort profile: demographic and clinical characteristics of the MILESTONE longitudinal cohort of young people approaching the upper age limit of their child mental health care service in Europe

PURPOSE

The presence of distinct child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) impacts continuity of mental health treatment for young people. However, we do not know the extent of discontinuity of care in Europe nor the effects of discontinuity on the mental health of young people. Current research is limited, as the majority of existing studies are retrospective, based on small samples or used non-standardised information from medical records. The MILESTONE prospective cohort study aims to examine associations between service use, mental health and other outcomes over 24 months, using information from self, parent and clinician reports.

PARTICIPANTS

Seven hundred sixty-three young people from 39 CAMHS in 8 European countries, their parents and CAMHS clinicians who completed interviews and online questionnaires and were followed up for 2 years after reaching the upper age limit of the CAMHS they receive treatment at.

FINDINGS TO DATE

This cohort profile describes the baseline characteristics of the MILESTONE cohort. The mental health of young people reaching the upper age limit of their CAMHS varied greatly in type and severity: 32.8% of young people reported clinical levels of self-reported problems and 18.6% were rated to be 'markedly ill', 'severely ill' or 'among the most extremely ill' by their clinician. Fifty-seven per cent of young people reported psychotropic medication use in the previous half year.

FUTURE PLANS

Analysis of longitudinal data from the MILESTONE cohort will be used to assess relationships between the demographic and clinical characteristics of young people reaching the upper age limit of their CAMHS and the type of care the young person uses over the next 2 years, such as whether the young person transitions to AMHS. At 2 years follow-up, the mental health outcomes of young people following different care pathways will be compared.

TRIAL REGISTRATION NUMBER

NCT03013595.

P–679 Magnetic resonance imaging (MRI), an alternative method to evaluate the ovarian reserve

Study question

Is magnetic resonance imaging (MRI) a valid method to access antral follicles count (AFC) compared to two-dimensional (2D) transvaginal ultrasonography (USG) and Anti-Mullerian Hormone (AMH) to evaluate the ovarian reserve?

Summary answer

AFC has a high agreement between MRI and USG methods, as well as with AMH. MRI can be an alternative method to evaluate ovarian reserve.

What is known already

In fact, two methods are the most used today to assess ovarian reserve: USG and AMH. The USG is considered the gold standard method for AFC, and contributes to predict and tailor treatment strategies, such as in-vitro fertilization. The major limitations of USG are its user dependency and equipment. Also, there are limitations in displaying a global view of the pelvis and large ovarian lesions. Magnetic resonance imaging (MRI), with its excellent soft-tissue contrast resolution and characteristics, is a useful non-invasive alternative modality to USG. Just one study evaluated MRI and revealed more small size antral follicles compared to 3D-USG.

Study design, size, duration

A prospective cross-sectional observational study was performed in an assisted reproduction techniques (ART) post-graduation program setting from an assisted reproductive center in Sao Paulo, Brazil, which ran throughout 2019–2020, with a total number of 59 patients that were in fertility treatment and needed to undergo to a MRI procedure to evaluate uterine or pelvic diseases as, Myoma, Adenomyosis, endometriosis, and adnexal cysts.

Participants/materials, setting, methods

Patients were evaluated to access the AFC by the MRI method and 2D transvaginal USG, and Anti-Mullerian Hormone (AMH) concentration to evaluate the ovarian reserve. Comparison between methods was done through Wilcoxon signed ranks test and Bland-Altman analysis. Ovarian reserve was classified as follows: very low (&lt;4 follicles/AMH&lt;0.5); low (5–7 follicles/AMH=0.5–1.1); normal (8–15 follicles/AMH=1.1–3.5); normal-high (&gt;15 follicles/AMH&gt;3.5). Weighted Cohen’s kappa was used to verify agreement between MRI, USG and AMH classifications of ovarian reserve.

Main results and the role of chance

Average AFC for USG were 5,55±4.01 for left ovary and 5.55±3.8 for right ovary. Average follicle count for both ovaries was 10±7.07. Regarding MRI, mean counts were 6.44±4.81 for left ovary, 5.65±3.85 for right ovary, and a 11.89±7.89 follicle sum mean count. Average concentration of AMH was 1.79±1.44. The Wilcoxon test and Bland-Altman analyses found differences and systematic biases for comparison between USG and MRI for both ovaries (–2.58; limits of agreement=–14.56 to 9.40, Wilcoxon p = 0,008) and for the right ovary (–1.48; limits of agreement=–8.32 to 5.35, Wilcoxon p = 0,031). There was no difference between methods for the left ovary. Weighted Cohen Kappa coefficients showed substantial agreement between ovarian reserve classifications based on AMH levels, USG, and MRI. The conducted paired comparisons were USG with MRI (k = 0.676), AMH with MRI (k = 0.760) and USG (k = 0.609).

Limitations, reasons for caution

The systematic biases found when comparing USG to MRI methods may suggest a consistent detection of more follicles with MRI procedures in comparison to the USG method. This bias found warrants caution as it must be confirmed, in future studies.

Wider implications of the findings: The MRI method reveals similar ovarian reserve to USG when used the same classification, and a higher agreement to AMH. This suggests that MRI is a reliable method of quantifying antral follicles and can also be adopted when the patient will need to evaluate pelvic pathologies.

Trial registration number

Not applicable

Prospective multicentre study on azole resistance in Aspergillus isolates from surveillance cultures in haematological patients in Italy

OBJECTIVES

This study was conducted to assess the prevalence of azole resistance in Aspergillus isolates from patients with haematological malignancies or who were undergoing haematopoietic stem cell transplantation and to identify the molecular mechanism of resistance.

METHODS

In this 28-month prospective study involving 18 Italian centres, Aspergillus isolates from surveillance cultures were collected and screened for azole resistance, and mutations in the cyp51A gene were identified. Resistant isolates were genotyped by microsatellite analysis, and the allelic profiles were compared with those of resistant environmental and clinical isolates from the same geographical area that had been previously genotyped.

RESULTS

There were 292 Aspergillus isolates collected from 228 patients. The isolates belonged mainly to the section Fumigati (45.9%), Nigri (20.9%), Flavi (16.8%) and Terrei (4.8%). Three isolates showed itraconazole resistance: Aspergillus fumigatus sensu stricto, Aspergillus lentulus (section Fumigati) and Aspergillus awamori (section Nigri). The itraconazole resistance rates were 1% and 1.48% considering all Aspergillus spp. isolates and the Aspergillus section Fumigati, respectively. The prevalence of azole resistance among all the patients was 1.3%. Among patients harbouring A. fumigatus sensu stricto isolates, the resistance rate was 0.79%. The A. fumigatus isolate, with the TR₃₄/L98H mutation, was genotypically distant from the environmental and clinical strains previously genotyped.

CONCLUSIONS

In this study, the Aspergillus azole resistance rate was 1% (3/292). In addition to A. fumigatus sensu stricto, A. lentulus and A. awamori azole-resistant isolates were identified. Therefore, it is important have a correct identification at the species level to address a rapid therapy better, quickly understand the shift towards cryptic species and have an updated knowledge of the local epidemiology.

Prenatal natural history of congenital pulmonary malformations: MALFPULM population-based cohort study

OBJECTIVES

To assess prenatal changes in the volume of congenital pulmonary malformations (CPM) and examine whether these changes differ in lesions that appear cystic on ultrasound compared with hyperechoic lesions, and to study the relationship between CPM volume and risk of fetal compression.

METHODS

We conducted a nationally representative, multicenter, prospective cohort study, which included 579 ultrasound examinations in 176 pregnant women with a diagnosis of fetal CPM, between March 2015 and November 2016. Several ultrasound examinations were performed between diagnosis and delivery, including measurement of CPM volume. We modeled changes in CPM volume ratio (CVR) as a function of gestational age, overall and for cystic/mixed vs hyperechoic malformations, and examined the association between CVR and signs of compression during pregnancy.

RESULTS

When modeling CVR changes over time, there was a statistically significant decrease in CVR with increasing gestational age (P < 0.001), but the pattern of change differed according to CPM phenotype at first ultrasound examination: cystic/mixed CPM were characterized by a monotonic decrease in CVR with increasing gestational age (P = 0.002), whereas hyperechoic CPM showed an initial increase in CVR up to 27 weeks of gestation, followed by a decrease thereafter (P < 0.001). Peak CVR values were predicted as early as 21-22 weeks for cystic/mixed CPMs compared with 25-26 weeks for hyperechoic malformations. Regardless of CPM phenotype, fetuses that showed no sign of compression at any point had substantially lower CVR at first CVR measurement, and the CVR remained relatively constant thereafter. Among the subpopulation of fetuses with no sign of compression at first CVR measurement, the odds of a subsequent compression was 7-fold higher (adjusted odds ratio, 7.0; 95% CI, 1.6-29.9) if initial CVR was > 0.4 vs CVR ≤ 0.4 cm² .

CONCLUSIONS

Predicted changes in CVR during pregnancy differ between cystic and hyperechoic malformations. This may be the result of different pathophysiological mechanisms or differences in the timing of occurrence of these different types of CPM. CVR measured at the initial diagnostic ultrasound examination was strongly associated with the odds of subsequent compression. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Persistent hematogenous dissemination in pulmonary P. jiroveci infection

Pneumocystis jiroveci pneumonia in non-HIV patients is infrequent and characterized by atypical presentations and increased severity. Although hematogenous dissemination from the lungs can lead to extrapulmonary infections, isolation of oocysts from blood in human subjects has not been documented. We report a case of P. jiroveci pneumonia with persistent isolation of oocysts from blood and positivity of P. jiroveci polymerase chain reaction. The patient presented with bilateral diffuse pulmonary nodules and received prolonged treatment with trimethoprim/sulfamethoxazole.

Prognosis of isolated congenital diaphragmatic hernia using lung-area-to-head-circumference ratio: variability across centers in a national perinatal network

OBJECTIVE

Congenital diaphragmatic hernia (CDH) is a severe anomaly. The observed-to-expected lung-area-to-head-circumference ratio (o/e-LHR) has been shown to provide a useful prediction of subsequent survival of fetuses with CDH in referral centers with expertise and a large caseload. However, the accuracy of o/e-LHR measurements in general fetal medicine units with less expertise is not well known. The aim of this study was to evaluate the capacity of o/e-LHR to provide a useful prediction of mortality of fetuses with CDH when the measurement is performed in fetal medicine units with different levels of expertise.

METHODS

Between January 2008 and November 2013, 305 live births with expectantly managed left-sided isolated CDH were recorded in the database of the French National Center for Rare Diseases (31 centers) and followed up after birth. Centers were grouped into two categories according to their mean annual CDH caseload over the study period: large centers with an average of ≥ 14 cases and smaller centers with < 14 cases per year. The relationship between o/e-LHR and 28-day and 6-month mortality was modeled using fractional polynomials and the predictive value of o/e-LHR was quantified using the area under the receiver-operating characteristics curve. Comparisons between the two center categories were carried out. Analyses were adjusted for potential confounders such as thoracic herniation of the liver and gestational age at birth and at diagnosis.

RESULTS

During the study period, two large centers managed a total of 82 CDH cases and 29 smaller centers a total of 223 CDH cases. Overall, there was a significant inverse relationship between 28-day mortality rate and o/e-LHR, which decreased from 54% when o/e-LHR was 20% to 6% when o/e-LHR was 75% (P < 0.01). When the category of center was considered, adjusted associations between o/e-LHR and 28-day mortality were significantly different (P = 0.032) between large and smaller centers. The ability to predict survival at 28 days postpartum based on o/e-LHR was better in large centers; for a specificity of 0.30, the sensitivity was 0.71 in large centers and 0.55 in smaller ones. The results were similar for 6-month mortality.

CONCLUSIONS

Our results show that o/e-LHR measured on two-dimensional ultrasound is a good indicator of neonatal prognosis in cases of CDH that may be used even in fetal medicine centers with a small caseload. However, our results also suggest that LHR measurement may be difficult to perform correctly. Therefore, appropriate training should be offered to professionals. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

[Lowe syndrome revealed by prenatal diagnosis of congenital cataract with brain abnormalities]

Congenital cataract is a rare disease whose incidence is estimated to 0.5% of birth in France. A study of the literature shows that congenital cataract is idiopathic in 50% of cases, hereditary forms representing 25% of cases. Other causes of congenital cataract are represented by viral embryofoetopathies acquired during pregnancy, metabolic disorders and chromosomal aberrations within the scope of malformative syndromes. The authors report the case of a neonatal diagnosis of Lowe syndrome suspected by the discovery of bilateral cataract initially isolated. The morphological exploration was completed by secondary brain abnormalities (periventricular lesions). The etiological prenatal exploration was negative. Lowe syndrome is a rare cause of antenatal cataract, which so far only one case has been reported.

Evolution of middle cerebral artery peak systolic velocity after a successful laser procedure for iatrogenic twin anemia-polycythemia sequence

We report a case of twin anemia-polycythemia sequence (TAPS) treated by laser at 24 + 5 weeks' gestation, 7 weeks after a first laser procedure for twin-to-twin transfusion syndrome at 16 + 6 weeks. This management led to the birth of two healthy neonates by Cesarean section at 36 weeks. In this case, weekly measurement of the middle cerebral artery peak systolic velocity allowed us to monitor the twins after both laser treatments and, more specifically, to detect TAPS. Following delivery, placental injection showed a minuscule coagulated arteriovenous anastomosis. Intrauterine transfusion is generally chosen to manage TAPS, but the choice of therapy must consider gestational age, technical difficulties and disease severity. The laser procedure cannot be used as a curative treatment for TAPS in all cases. We propose a decisional algorithm to help clinicians select the appropriate treatment.

[Unusual fetal teratoma presenting as a posterior mediastinal cyst]

Mediastinal cysts are uncommon prenatal findings. As isolated and non-compressing entities, they don't compromise the course of gestation. Massive lesions can compress vital structures, resulting in fetal demise. Thus, close follow-up with sonographic monitoring is recommended until birth. Non-hydroptic fetuses can be managed expectantly. Definitive etiology is known after surgical resection only. We present the first case of posterior mediastinal teratoma associated with severe vertebral abnormalities. After CT scan and fetal MRI, medical termination of pregnancy was decided. Histological examination revealed an immature teratoma. With this unique case report, we discuss the optimal prenatal management of mediastinal cysts.

Maladie de Paget de la vulve : intérêt de l'étude du ganglion sentinelle

Paget's disease of the vulva is difficult to diagnose, as far as the extent of this lesion is concerned, since it is often coupled with invasive adenocarcinoma of the vulva. Thus, we present two cases of Paget's disease of the vulva, with use of sentinel lymph node analysis- a non-validated technique in this very context. Evaluation of sentinel lymph node may be useful in case of micro-invasive Paget's disease.

Post-discharge surveillance: can patients reliably diagnose surgical wound infections?

Post-discharge surgical wound infection surveillance is an important part of many infection control programs. It is frequently undertaken by patient self-assessment, prompted either by a telephone or postal questionnaire. To assess the reliability of this method, 290 patients were followed for six weeks postoperatively. Their wounds were photographed and also covertly assessed for signs of infection by two experienced infection control nurses (ICNs). Patients also responded to a postal questionnaire seeking evidence of infection at both week four and week six post-surgery. Correlation between the patient's assessment of their wound and the ICNs diagnosis was poor (r = 0.37) with a low positive predictive value (28.7%), although negative predictive value was high (98.2%). Assessment of photos for signs of infection by two experienced clinicians also correlated poorly with the ICNs diagnosis of infection (r = 0.54). The patient's recall of prescription of an antibiotic by their general practitioner (GP) for wound infection during the postoperative period correlated best with the ICNs diagnosis (r = 0.76). This latter measure, particularly when confirmed by the GP in those patients reporting an infection, appears to provide the most valid and resource efficient marker of post-discharge surgical wound infection.

The application of statistical process control charts to the detection and monitoring of hospital-acquired infections

The monitoring of infection control indicators including hospital-acquired infections is an established part of quality maintenance programmes in many health-care facilities. However, surveillance data use can be frustrated by the infrequent nature of many infections. Traditional methods of analysis often provide delayed identification of increasing infection occurrence, placing patients at preventable risk. The application of Shewhart, Cumulative Sum (CUSUM) and Exponentially Weighted Moving Average (EWMA) statistical process control charts to the monitoring of indicator infections allows continuous real-time assessment. The Shewhart chart will detect large changes, while CUSUM and EWMA methods are more suited to recognition of small to moderate sustained change. When used together, Shewhart and EWMA methods are ideal for monitoring bacteraemia and multiresistant organism rates. Shewhart and CUSUM charts are suitable for surgical infection surveillance.