Maternal and fetal outcomes after planned cesarean or vaginal delivery in twin pregnancy: a comparison between 2 third level birth centers.

BACKGROUND: Twin pregnancy is associated with higher risks of adverse perinatal outcomes for both the mother and the babies. Among the many challenges in the follow-up of twin pregnancies, the mode of delivery is the last but not the least decision to be made, with the main influencing factors being amnionicity and fetal presentation. The aim of the study was to compare perinatal outcomes in two European centers using different protocols for twin birth in case of non-cephalic second twin; the Italian patients being delivered mainly by cesarean section with those in Belgium being routinely offered the choice of vaginal delivery (VD). METHODS: This was a dual center international retrospective observational study. The population included 843 women with a twin pregnancy ≥ 32 weeks (dichorionic or monochorionic diamniotic pregnancies) and a known pregnancy outcome. The population was stratified according to chorionicity. Demographic and pregnancy data were reported per pregnancy, whereas neonatal outcomes were reported per fetus. We used multiple logistic regression models to adjust for possible confounding variables and to compute the adjusted odds ratio (adjOR) for each maternal or neonatal outcome. RESULTS: The observed rate of cesarean delivery was significantly higher in the Italian cohort: 85% for dichorionic pregnancies and 94.4% for the monochorionic vs 45.2% and 54.4% respectively in the Belgian center (p-value < 0.001). We found that Belgian cohort showed significantly higher rates of NICU admission, respiratory distress at birth and Apgar score of < 7 after 5 min. Despite these differences, the composite severe adverse outcome was similar between the two groups. CONCLUSION: In this study, neither the presentation of the second twin nor the chorionicity affected maternal and severe neonatal outcomes, regardless of the mode of delivery in two tertiary care centers, but VD was associated to a poorer short-term neonatal outcome.

Emotional exhaustion and fear of COVID-19 in geriatric facilities during the COVID-19 pandemic.

OBJECTIVE: Since the onset of the COVID-19 pandemic, healthcare workers, especially those employed in hospital settings, have been exposed to a variety of stressors in the workplace. The aim of this study was to explore the Emotional Exhaustion (EE) of workers in geriatric facilities during the COVID-19 crisis. We accordingly sought to investigate the short-term impact of the COVID-19 pandemic in terms of the EE experienced by workers in geriatric facilities, and to examine the manner in which psychosocial conditions and fear of COVID-19 in the workplace have affected EE. METHODS: Surveys were administered in the midst of the COVID-19 crisis (October to December 2020). The study included 118 French healthcare workers with a mean age of 35.61 ± 0.73 recruited in geriatric facilities. We assessed EE, psychosocial conditions (e.g., demands at work, health and well-being, etc.) and fear of COVID-19 in the workplace. RESULTS: The analysis yielded two main outcomes. First, 34.75% workers (41) reported severe levels of EE. Second, demands at work and the fear of COVD-19 increased EE. Health and well-being were, however, demonstrated to protect against EE. DISCUSSION: Furthermore, fear of COVID-19 was shown to contribute significantly to EE healthcare workers in geriatric facilities. It is likely that Covid-19 indirectly contributes to EE by influencing demands at work.

Evaluation of the new expert consensus-based definition of selective fetal growth restriction in monochorionic pregnancies.

OBJECTIVE: To compare the outcomes of a cohort of monochorionic pregnancies with selective fetal growth restriction (sFGR) diagnosed according to the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) definition published in 2015 with a cohort considered as sFGR according to new expert consensus-based diagnostic parameters published in 2019. METHODS: This was a retrospective study, conducted between January 1st 2010 and July 30th 2019. We reviewed the medical records of all the monochorionic pregnancies followed in our center including perinatal outcomes. Pregnancies complicated by fetal anomalies, infection, twin-twin transfusion syndrome, twin anaemia-polycythemia sequence and twin reversed arterial perfusion sequence were excluded. Patients were grouped according to the 2015 ISUOG definition into: normal (Group 1), sFGR (Group 2), and monochorionic pregnancies with abnormal growth that did not fulfill the full criteria for sFGR (Group 3). After the initial classifications were made, an additional group, was created, including all pregnancies reclassified as sFGR according to the 2019 expert consensus parameters (Group 4). RESULTS: During the study period, 291 monochorionic pregnancies were followed in our center, 132 of whom were eligible for inclusion in the final analysis. The prevalence of sFGR increased from 17.4% to 26.5% after applying the expert consensus-based parameters to the study population. Compared to group 1, group 2 had higher rates of emergency cesarean, neonatal intensive care admissions, invasive and noninvasive ventilation, surfactant use, metabolic disorders and lower gestational ages at birth. In contrast, the neonatal outcomes of Groups 1 and 4 were not significantly different. CONCLUSION: When the 2019 consensus-based diagnostic parameters for sFGR were applied to our study population, the number of sFGR cases increased by over 50%, without any improvements in perinatal outcomes. Larger prospective studies are needed to examine the potential clinical implications of these new parameters for sFGR in monochorionic pregnancies.

Prenatal prediction of postnatal survival in fetuses with congenital diaphragmatic hernia using MRI: lung volume measurement, signal intensity ratio, and effect of experience.

OBJECTIVE: To evaluate various signal intensity ratios in isolated congenital diaphragmatic hernia (CDH) and to compare their potential in predicting survival with that of the observed-to-expected (O/E) ratio of total fetal lung volume (TFLV) using magnetic resonance imaging (MRI) measurements. Our second objective was to evaluate the impact of operator's experience in comparing the prediction of postnatal survival by O/E-TFLV. METHODS: In 75 conservatively managed CDH fetuses and in 50 who underwent fetoscopic endoluminal tracheal occlusion (FETO), the fetal lung-to-amniotic fluid, lung-to-liver, lung-to-muscle, lung-to-spinal fluid signal intensity ratios, respectively LAFSIR, LLSIR, LMSIR, and LSFSIR, were measured, as was O/E-TFLV. Receiver operating characteristic (ROC) curves were constructed and used to compare the various signal intensity ratios with O/E-TFLV in the prediction of postnatal survival. In 72 MRI lung volumes assessed by the referring radiologists in Paris and Lille and secondarily by our expert radiologist in Brussels (M.M.C.) using the same MRI examinations, ROC curves were constructed and used to compare the value of O/E-TFLV determined by the two centers in the prediction of postnatal survival. RESULTS: In the total cohort of CDH fetuses, O/E-TFLV and LLSIR were predictive of postnatal survival whereas in the conservatively managed group O/E-TFLV, LLSIR, and LMSIR predicted postnatal survival. O/E-TFLV predicted postnatal survival far better than the signal intensity ratios: area under the ROC curve for prediction by O/E-TFLV in the total cohort was 0.866 (p < .001; standard error = 0.031). The area under the ROC curve for prediction of postnatal survival using O/E-TFLV by MRI evaluated at the referral centers was 0.640 (p = 102; standard error = 0.085), and with O/E-TFLV reevaluated by M.M.C., it was 0.872 (p < .001; standard error = 0.061). Pairwise comparison showed a significant difference between the areas under the ROC curves (difference = 0.187, p = .012; standard error = 0.075). CONCLUSION: In fetuses with CDH with/without FETO, LLSIR was significantly correlated with the prediction of postnatal survival. However, measurement of O/E-TFLV was far better in predicting postnatal outcome. Operator experience in measurement of lung volumes using MRI seem to play a role in the predictive value of the technique.

The impact of family history of non-syndromic oral clefts on their incidence in pregnancy.

BACKGROUND AND OBJECTIVE: Orofacial clefts are the most commonly diagnosed birth defects of the face during pregnancy. They can be either syndromic or non-syndromic. The objective of this study was to calculate the incidence of non-syndromic cleft lip with or without cleft palate (CL/CP) and isolated cleft palate (CP) in patients with a positive family history of non-syndromic oral clefts, and to identify the familial risk factors of oral cleft development in these patients. METHODS: This was a retrospective study that included all patients with a positive family history of non-syndromic oral clefts, followed up in the department of fetal medicine in Brugmann University Hospital, Brussels, Belgium, between 1 January 2009 and 31 December 2019. RESULTS: Over the study period, the incidence of non-syndromic oral clefts was 10.81/10,000 pregnancies. Seventy-three (0.15%) women had a positive family history of oral clefts, and had 86 pregnancies during this period. The incidence of oral clefts in this group was 9.3% (86-fold increase). This incidence varied depending on many factors, including the type of oral clefts in the family, the degree of relation of the fetus or baby to the family member who has the cleft, and the number of siblings with oral clefts. CONCLUSION: The offspring of pregnant patients with a positive family history of oral clefts are at risk for recurrence. The incidence is very high when there are 3 or more siblings with oral clefts, when the father or mother has the anomaly, or when there is bilateral CL/CP in the family history.

Antenatal management and neonatal outcomes of monochorionic twin pregnancies in a tertiary teaching hospital: a 10-year review.

Monochorionic (MC) pregnancy is a high risk pregnancy with well-defined specific complications, such as twin-to-twin transfusion syndrome (TTTS) and twin anaemia-polycythaemia sequence (TAPS). Laser photocoagulation (LPC) is an effective treatment for both complications. In the current retrospective study, we determined the incidence of MC pregnancy complications in a tertiary care centre during a 10-year period. Single foetal death (FD) beyond 14 weeks' gestation was significantly higher when complicated by either TTTS, TAPS or selective foetal growth restriction (21.4%, 16.7% and 9.1% versus 1.6%, p<.001, p=.02 and p=.04, respectively). We also demonstrated that twins' weight discordance >20% is an independent risk factor for single or double FD after LPC. Consequently, prior to LPC, patients should be counselled that early diagnosis of TTTS, advanced Quintero stages and weight discordances >20% are potential risk factors for FD. Further studies are needed to identify additional risk factors for TTTS and TAPS outcome after LPC.Impact StatementWhat is already known on this subject? Monochorionic (MC) pregnancy is a high risk pregnancy with well-defined specific complications, such as twin-twin transfusion syndrome (TTTS) and twin anaemia-polycythaemia sequence (TAPS). Laser photocoagulation (LPC) is an effective treatment for both complications.What the results of this study add? The results of the current study determined the incidence of MC pregnancy complications in a tertiary care centre in Brussels, and identified that twins' weight discordance >20% is an independent risk factor for single or double foetal death after LPC.What the implications are of these findings for clinical practice and/or further research? Prior to laser coagulation, patients should be counselled that early diagnosis of TTTS, Quintero stages 3 or 4 and weight discordances >20% are potential risk factors for foetal demise. Further studies are needed to identify additional risk factors for TTTS and TAPS outcome after LPC.

A biocompatible porous Mg-gallate metal-organic framework as an antioxidant carrier.

A microporous magnesium gallate MOF was prepared from highly biocompatible reagents under environmentally friendly conditions. Its slow degradation in physiological fluids leads to the release of gallic acid and hence a high antioxidant activity, which was illustrated in the HL-60 cell line.

Comparison of models to predict nonsentinel lymph node status in breast cancer patients with metastatic sentinel lymph nodes: a prospective multicenter study.

PURPOSE: Several models have been developed to predict nonsentinel lymph node (non-SN) status in patients with breast cancer with sentinel lymph node (SN) metastasis. The purpose of our investigation was to compare available models in a prospective, multicenter study. PATIENTS AND METHODS: In a cohort of 561 positive-SN patients who underwent axillary lymph node dissection, we evaluated the areas under the receiver operating characteristic curves (AUCs), calibration, rates of false negatives (FN), and number of patients in the group at low risk for non-SN calculated from nine models. We also evaluated these parameters in the subgroup of patients with micrometastasis or isolated tumor cells (ITC) in the SN. RESULTS: At least one non-SN was metastatic in 147 patients (26.2%). Only two of nine models had an AUC greater than 0.75. Three models were well calibrated. Two models yielded an FN rate less than 5%. Three models were able to assign more than a third of patients in the low-risk group. Overall, the Memorial Sloan-Kettering Cancer Center nomogram and Tenon score outperform other methods for all patients, including the subgroup of patients with only SN micrometastases or ITC. CONCLUSION: Our study suggests that all models do not perform equally, especially for the subgroup of patients with only micrometastasis or ITC in the SN. We point out available evaluation methods to assess their performance and provide guidance for clinical practice.

Maternal serum screening in cases of mosaic and translocation Down syndrome.

OBJECTIVES: To determine if the second-trimester maternal serum markers (MSM) screening for Down syndrome (DS) is efficient in DS mosaicism or structural rearrangement cases. METHOD: DS mosaic or translocation cases were reviewed from databases of routine MSM DS screening. The control group consisted of 977 trisomy 21 cases included in a series of 854 902 patients (routine screening). DS risk was calculated by combination of maternal age and MSM [alpha-fetoprotein (AFP) and human choriogonadotrophin (hCG) or free beta-hCG and/or uE3] expressed in multiples of median (MoM). Mosaic DS cases were divided into three groups, < 10%, 10-49%, and >or= 50% trisomy 21 cells. Translocation DS cases were divided into three groups, isochromosome, Robertsonian, or reciprocal translocation. Detection rate (DR) and MoMs were evaluated in each group. RESULTS: As many as 76 cases of nonstandard trisomy 21 were collected. For mosaic DS cases (n = 43) DR was 69.8% (not significantly different from the 70.8% of control group). When mosaicism was less than 10%, the DR dropped to 25%. For translocation DS cases (n = 33) DR was 75.7% (not significantly different from control group) whatever the types of translocation. CONCLUSION: In the nonstandard DS cases, second-trimester MSMs gave the same detection rate as for standard trisomy 21, except the cases with low-level mosaicism (<10%).

Efficacy and safety of tenofovir double-dose in treatment-experienced HIV-infected patients: the TENOPLUS study.

Drug resistance is an increasing problem in the treatment of HIV infection. Tenofovir has been shown to inhibit HIV replication even with thymidine-associated resistance mutations (TAMs) if they are limited to two or less. Double-dose of tenofovir disoproxil fumarate (TDF) (600 mg QD) was used to determine weather the drug could be virologically effective in patients harbouring HIV-strains resistant to nucleoside analogues (NRTI). A pilot, open, non-comparative add-on study, where patients failing a current antiretroviral regimen, with at least two TAMs, and naive for tenofovir, were given tenofovir 600 mg once-daily for 4 weeks, in addition to their current failing antiretroviral regimen. The primary end-point was the percentage of patients with plasma viral load (VL) reduction of at least 0.8 log(10) between baseline and week 4 (W4). Ten patients were enrolled. At baseline, the median viral load was 3.66 log(10) copies/ml (range 3.13-4.03) and the median CD4 cell count was 407/mm(3) (range 136-1102). The percentage of patients with reduction the viral load > or =0.8 log(10) was 40% at W4. After 4 weeks of treatment with tenofovir 600 mg, the median decrease in the viral load was -0.61 log(10) (range -0.05; -0.88) and the median gain of CD4 was +109/mm(3). Despite a twofold increase tenofovir plasma concentrations, no serious drug-related adverse event were recorded except for one patient experiencing an de Fanconi syndrome at week 2. This add-on pilot study supports the concept of double dose tenofovir to virologically overcome the decreased sensitivity of NRTI-resistant viruses. However, the safety of this regimen needs to be considered carefully.

Polylactic acid implants (New-Fill) to correct facial lipoatrophy in HIV-infected patients: results of the open-label study VEGA.

BACKGROUND: In the absence of currently available therapy to manage facial lipoatrophy, strategies used to compensate for facial fat loss warrant clinical evaluation. METHODS: The goal of this open-label, single-arm, pilot study was to evaluate the efficacy and safety of facial injections of poly-L-lactic acid (PLA) (New-Fill) in HIV-infected patients with severe facial lipoatrophy. Patients received four sets of injection at day 0 and then every 2 weeks for 6 weeks. Patients were evaluated by clinical examination, facial ultrasonography, and photography at screening and at weeks 6, 24, 48, 72, and 96. RESULTS: Fifty patients were enrolled. At entry, the median facial fat thickness was equal to zero (range, 0.0-2.1 mm). The median total cutaneous thickness (TCT) increased significantly from baseline : +5.1 mm (range, 2.2-8.6 mm) at week 6, +6.4 mm (range, 3.1-9.1 mm) at week 24, +7.2 mm (range, 4.2-9.6 mm) at week 48, +7.2 mm (range, 3.5-9.6 mm) at week 72 and +6.8 mm (range, 3.9-10.1 mm) at week 96 (P < 0.001). The proportion of patients with TCT > 10 mm was observed in 19% at week 6, 41% at week 24, 61% at week 48, 52% at week 72 and 43% at week 96. In 22 (44%) patients, palpable but non-visible subcutaneous micronodules were observed with a spontaneous resolution in six patients at week 96. CONCLUSION: The benefit of PLA for the correction of the facial lipoatrophy in HIV-infected patients was clearly demonstrated, with an evident aesthetic and quality of life improvement. The efficacy, safety profile, and the simplicity of the injection schedule of PLA make this filling material a potentially attractive treatment.