Knowledge, Attitudes, and Challenges: Irish General practitioners' preparedness for publicly funded Assisted reproductive technologies.

OBJECTIVES: Global access to assisted reproductive technologies (ART) remains highly inequitable. Until recently, access to ART in Ireland was solely available through private fertility clinics. Publicly funded ART was introduced in September 2023 but eligibility requires patients to meet strict access criteria that include referral by their primary care general practitioner (GP) to the local fertility service. Previous studies report that fertility training amongst doctors, including GPs, is variable and an obstetrics and gynaecology (O&G) rotation is not mandatory for GP trainees in Ireland. This study aimed to investigate GPs' knowledge of fertility investigations and management, as well as attitudes towards publicly funded ART access criteria. STUDY DESIGN: A cross-sectional online survey was distributed to GPs working in Ireland between September 2023 and January 2024. The survey questionnaire explored attitudes to, and knowledge of, ART including the publicly funded access criteria. Responses to free-text questions were qualitatively analysed using content analysis. RESULTS: The study had 154 respondents, representing approximately 4 % of GPs in Ireland. Three quarters (n = 120, 78 %) of respondents were female, 68 % (n = 105) had completed an O&G training rotation and 72 % (n = 111) had further O&G qualifications. However, 69 % (n = 107) reported that they had no training in subfertility investigation and management, and 34 % (n = 53) were not aware of the access criteria for publicly funded ART prior to completing the survey. Almost all GPs (97 %, n = 149) felt that they would benefit from more education on fertility. Qualitative content analysis generated two themes regarding publicly funded ART: (i) the access criteria are too restrictive and (ii) the workload for GPs will increase. CONCLUSIONS: GPs in Ireland are now being tasked with managing infertility and fertility treatment referrals, but most have not been provided with sufficient training. Our study shows that GPs in Ireland desire broader access criteria for publicly funded ART and better fertility training and education for their own clinical practice.

Amniocentesis in pregnancies at or beyond 24 weeks: an international multicenter study.

BACKGROUND: Amniocentesis for genetic diagnosis is most commonly done between 15 and 22 weeks of gestation but can be performed at later gestational ages. The safety and genetic diagnostic accuracy of amniocentesis have been well-established through numerous large-scale multicenter studies for procedures before 24 weeks, but comprehensive data on late amniocentesis remain sparse. OBJECTIVE: To evaluate the indications, diagnostic yield, safety, and maternal and fetal outcomes associated with amniocentesis performed at or beyond 24 weeks of gestation. STUDY DESIGN: We conducted an international multicenter retrospective cohort study examining pregnant individuals who underwent amniocentesis for prenatal diagnostic testing at gestational ages between 24w0d and 36w6d. The study, spanning from 2011 to 2022, involved 9 referral centers. We included singleton or twin pregnancies with documented outcomes, excluding cases where other invasive procedures were performed during pregnancy or if amniocentesis was conducted for obstetric indications. We analyzed indications for late amniocentesis, types of genetic tests performed, their results, and the diagnostic yield, along with pregnancy outcomes and postprocedure complications. RESULTS: Of the 752 pregnant individuals included in our study, late amniocentesis was primarily performed for the prenatal diagnosis of structural anomalies (91.6%), followed by suspected fetal infection (2.3%) and high-risk findings from cell-free DNA screening (1.9%). The median gestational age at the time of the procedure was 28w5d, and 98.3% of pregnant individuals received results of genetic testing before birth or pregnancy termination. The diagnostic yield was 22.9%, and a diagnosis was made 2.4 times more often for fetuses with anomalies in multiple organ systems (36.4%) compared to those with anomalies in a single organ system (15.3%). Additionally, the diagnostic yield varied depending on the specific organ system involved, with the highest yield for musculoskeletal anomalies (36.7%) and hydrops fetalis (36.4%) when a single organ system or entity was affected. The most prevalent genetic diagnoses were aneuploidies (46.8%), followed by copy number variants (26.3%) and monogenic disorders (22.2%). The median gestational age at delivery was 38w3d, with an average of 59 days between the procedure and delivery date. The overall complication rate within 2 weeks postprocedure was 1.2%. We found no significant difference in the rate of preterm delivery between pregnant individuals undergoing amniocentesis between 24 and 28 weeks and those between 28 and 32 weeks, reinforcing the procedure's safety across these gestational periods. CONCLUSION: Late amniocentesis, at or after 24 weeks of gestation, especially for pregnancies complicated by multiple congenital anomalies, has a high diagnostic yield and a low complication rate, underscoring its clinical utility. It provides pregnant individuals and their providers with a comprehensive diagnostic evaluation and results before delivery, enabling informed counseling and optimized perinatal and neonatal care planning.

Updates in preimplantation genetic testing (PGT).

Preimplantation genetic testing (PGT) involves taking a biopsy of an early embryo created through in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI). Genetic testing is performed on the biopsy, in order to select which embryo to transfer. PGT began as an experimental procedure in the 1990s, but is now an integral part of assisted human reproduction (AHR). PGT allows for embryo selection which can reduce the risk of transmission of inherited disease and may reduce the chance of implantation failure and pregnancy loss. This is a rapidly evolving area, which raises important ethical issues. This review article aims to give a brief history of PGT, an overview of the current evidence in PGT along with highlighting exciting areas of research to advance this technology.

Considerations for using potential surrogate endpoints in cancer screening trials.

The requirement of large-scale expensive cancer screening trials spanning decades creates considerable barriers to the development, commercialisation, and implementation of novel screening tests. One way to address these problems is to use surrogate endpoints for the ultimate endpoint of interest, cancer mortality, at an earlier timepoint. This Review aims to highlight the issues underlying the choice and use of surrogate endpoints for cancer screening trials, to propose criteria for when and how we might use such endpoints, and to suggest possible candidates. We present the current landscape and challenges, and discuss lessons and shortcomings from the therapeutic trial setting. It is hugely challenging to validate a surrogate endpoint, even with carefully designed clinical studies. Nevertheless, we consider whether there are candidates that might satisfy the requirements defined by research and regulatory bodies.

A roadmap to precision treatments for familial pulmonary fibrosis.

Interstitial lung diseases (ILDs) in adults and children (chILD) are a heterogeneous group of lung disorders leading to inflammation, abnormal tissue repair and scarring of the lung parenchyma often resulting in respiratory failure and death. Inherited factors directly cause, or contribute significantly to the risk of developing ILD, so called familial pulmonary fibrosis (FPF), and monogenic forms may have a poor prognosis and respond poorly to current treatments. Specific, variant-targeted or precision treatments are lacking. Clinical trials of repurposed drugs, anti-fibrotic medications and specific treatments are emerging but for many patients no interventions exist. We convened an expert working group to develop an overarching framework to address the existing research gaps in basic, translational, and clinical research and identified areas for future development of preclinical models, candidate medications and innovative clinical trials. In this Position Paper, we summarise working group discussions, recommendations, and unresolved questions concerning precision treatments for FPF.

Uptake rates and attitudes to influenza and COVID-19 vaccination in pregnancy - a prospective cohort study.

Influenza and COVID-19 are highly prevalent RNA viruses. Pregnancy increases the frequency of severe maternal morbidity and mortality associated with these viruses. Vaccination plays an important role in protecting pregnant women and their infants from adverse outcomes. In this prospective study, we aimed to determine the vaccination uptake rate for influenza and COVID-19 in a pregnant population and to explore reasons why women remained unvaccinated. A prospective cohort study was conducted over a two-week period in December 2022 in the National Maternity Hospital, Dublin. There were 588 women surveyed over the 2-week period. Overall, 377 (57%) were vaccinated that year for seasonal influenza, a significant rise from 39% in a similar study in 2016. The majority (n = 488, 83%) of women reported receiving at least one COVID-19 vaccine. However only 132 (22%) received a COVID-19 vaccine in pregnancy, despite 76% (n = 466) stating they would be happy to receive it. Factors such as age, obesity, co-morbidities, ethnic group, and type of antenatal care received were shown to influence vaccination rates. We recommend that the importance of vaccination be stressed regularly to eligible patients at their antenatal clinic visits and where possible combining influenza/COVID-19 vaccination on the same day to improve uptake.

Developing future clinical leaders in patient safety: the Irish experience.

INTRODUCTION: It is 20 years since the Institute of Medicine advocated a national approach to improve care and patient safety. Patient safety infrastructure has greatly improved in certain countries. In Ireland, patient safety infrastructure is in ongoing development. To contribute to this, the Royal College of Physicians of Ireland/International Society for Quality in Healthcare Scholar in Residence Programme was launched in 2016. This programme aims to improve patient safety and develop a movement of future clinician leaders to drive improvements in patient safety and the quality of care. METHODS: Doctors in postgraduate training complete a year-long immersive mentorship. This involves monthly group meetings with key patient safety opinion makers, one-on-one mentorship, leadership courses, conference attendance and presentations. Each scholar undertakes a quality improvement (QI) project. RESULTS: A QI project was associated with a decrease in caesarean section rates from 13.7% to 7.6% (p=0.0002) among women in spontaneous labour at term with a cephalic presentation. Other projects are ongoing. CONCLUSION: Medical error, patient safety and QI must be addressed comprehensively at both undergraduate and postgraduate level. We believe the Irish mentorship programme will help to change the paradigm and improve patient safety.

Pregnancy outcomes following recurrent miscarriage.

BACKGROUND: Recurrent miscarriage affects 1-2% of the population, and the literature has focussed on causes, treatment, and live birth rate. AIM: This study aimed to assess the reproductive outcomes for patients who attended a specialist recurrent miscarriage clinic for investigation and treatment. METHODS: Prospective analysis of all patients who attended a recurrent miscarriage clinic from January 2014 to January 2021. RESULTS: Of the 488 patients who attended a specialist clinic, 318 had a further pregnancy with 299 included in this study. The median age was 37 years, with 55.6% having a previous live birth. The subsequent live birth rate was 75.3%, 22.0% had a further pregnancy loss, 1.7% had an ongoing pregnancy, and 1% attended another institution after the second trimester. The rate of preeclampsia was 2.2%, pregnancy-induced hypertension was 2.2%, fetal growth restriction was 5.3%, preterm birth ≤ 34 weeks was 1.8%, and preterm birth > 34 weeks < 37 weeks was 6.6%. CONCLUSION: Patients who attend a dedicated recurrent miscarriage clinic for investigation and treatment have a high live birth rate in a subsequent pregnancy. A subsequent pregnancy following recurrent pregnancy loss does not appear to be associated with an increased risk of adverse pregnancy outcomes.

Second-trimester miscarriage: a review of postnatal investigations and subsequent pregnancy outcomes.

BACKGROUND: Second-trimester loss is pregnancy loss after the 12th and before the 24th completed weeks of pregnancy. This study aims to review cases of second-trimester miscarriage who attended a large maternity hospital and to examine pregnancy outcomes in this group of women. METHODS: This study is a review of cases of second-trimester miscarriage using descriptive, exploratory design, involving a retrospective chart review. RESULTS: In this study, 106 cases of second-trimester miscarriage were reviewed. The cause of the miscarriage was found in 42.5% (n = 45) of cases. The majority of women, 84.5% (n = 82) had a normal pelvic ultrasound scan and 18.3% (n = 17) of cases were diagnosed with antiphospholipid syndrome. In women who became pregnant again, 60.9% (n = 39) had a live birth. CONCLUSIONS: Establishing the cause of second-trimester miscarriage can be challenging, despite completing all recommended investigations. Outcomes in subsequent pregnancies are reassuring. This review highlights the need to undertake all recommended investigations to elicit the cause of second-trimester miscarriage and underpins the need for further research in this area.

Utilization of an Outpatient Integrated Infusion Suite to Decrease Length of Stay, Increase Revenue, and Improve Patient Experience for Elective Chemotherapy Admissions.

PURPOSE: Reduction of chemotherapy start times (CST) and length of stay (LOS) for elective chemotherapy admissions is a priority. The aim of this project was to improve efficiency of patient care while simultaneously increasing revenue by reducing LOS and transitioning high-cost chemotherapy to the outpatient setting. METHODS: A multidisciplinary quality improvement team proposed building a new outpatient infusion suite in close proximity to the inpatient unit. This suite was then integrated into the flow of elective inpatient chemotherapy admissions and discharges for etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (EPOCH-R). Quality measures such as CST, LOS, and revenue were used to evaluate the new infusion suite. RESULTS: In the pilot phase of the study, the average CST improved by approximately 1 hour 45 minutes (P = .0218). The mean LOS was reduced from 4.3 to 4.1 midnights (P = .0214). In terms of hours, LOS was reduced from 105.8 to 95.5 hours (P < .0001). A mean quarterly revenue of $309,410 US dollars was noted during the pilot that had not been previously billed. These improvements were sustained throughout the control phase. CONCLUSION: Delays in CST and prolonged LOS lead to patient dissatisfaction and increased cost to the health care system. Focus groups and patient feedback are important when designing and implementing new workflows. The creation of an outpatient integrated infusion suite allows medical centers to meet patients' expectations of reducing number of visits while also reducing LOS and capturing new revenue. Adherence to scheduling guidelines further reduces the CST for elective chemotherapy administration.