Transvaginal power Doppler ultrasound in pelvic congestion: A prospective comparison with transuterine venography

Purpose: Pelvic congestion is diagnosed by transuterine venography, an invasive procedure requiring sedation and irradiation. Ultrasound may be an alternative but is hindered by slow flow within pelvic veins. In an attempt to counter this, we investigated the possible role of transvaginal power Doppler ultrasound.

Material and Methods: 42 women with a clinical suspicion of pelvic congestion underwent transvaginal ultrasound. Adnexal veins were examined and a congestion score established. Planimetric measurements of adnexal vessels were obtained using power Doppler ultrasound, and uterine and ovarian morphology noted. All women then underwent transuterine venography and agreement with the ultrasound congestion score and morphologic features was determined.

Results: There was a trend towards weak positive correlation between ultrasound and venography congestion scores ( r = 0.29, p = 0.06). However, agreement between scores was poor on an individual basis (95% limits of agreement, −3.9 to +2.7). Planimetric power Doppler assessments of adnexal vascularity were unrelated to venographic congestion. Instead, there was correlation between the number and diameter of ovarian follicles and venographic congestion: women with congestion tended to have significantly more (0.04) and smaller follicles ( p = 0.001).

Conclusion: There was poor individual agreement between ultrasound and venographic estimates of congestion. However, there was a direct relationship between venographic congestion score and ovarian morphology.

Current Practices and Use of Simulation in Neonatal Resuscitation Program Courses Across Canada

BACKGROUND: Simulation is an effective tool in medical education. The extent and manner in which simulation is used within Neonatal Resuscitation Program (NRP) courses across Canada is currently unknown. In order to improve NRP education, current practices must be better understood.

OBJECTIVES: To characterize current practices and use of simulation in NRP courses across Canada.

DESIGN/METHODS: A REDCap survey, consisting of questions about instructor demographics, practices in NRP instruction and use of simulation, was developed and distributed to all NRP instructors across Canada. Simple statistics were used to tabulate responses and the chi-squared test was used to assess differences in simulation use between different types of instructors.

RESULTS: Five hundred sixty nine of 1390 (40.9%) NRP instructors completed the survey. Participants included 88 (15.5%) physicians, 74 (13.0%) respiratory therapists, 345 (60.6%) registered nurses and 28 (4.9%) nurse practitioners. Two hundred fifty eight (45.4%) worked in institutions providing Level III care. Overall, 560 (98.4%) respondents used simulation, of which only 176 (31.4%) reported using high-technology simulation. Only 180 (31.6%) instructors who used simulation reported having received formal training in high-technology simulation. When asked about the role of simulation in NRP instruction, 545 (95.8%) agreed or strongly agreed that simulation is a valuable educational tool in NRP instruction, but only 219 (39.1%) felt comfortable using high-technology simulation. There was no difference in use of high-technology simulation between physician and non-physician instructors (I2 0.90, p=0.34). Of the instructors who used high-technology simulation, 160 (90.9%) and 134 (76.1%) had learners and instructors, respectively, from multiple healthcare disciplines present in some or all sessions. There was a non-significant trend towards higher use of interprofessional learners among physician instructors (I2 3.8, p=0.052). An impressive 554 (98.9%) debriefed after some or all simulation sessions, with only 295 (51.8%) instructors having received formal training in debriefing techniques.

CONCLUSION: Almost all NRP instructors use simulation and feel that it is valuable, though few have received formal training and feel comfortable using high-technology simulation. Most simulation use is low-technology, in keeping with the Canadian Paediatric Society (CPS) recommendations, though the optimal methods of use of simulation in NRP instruction are not known. The majority of instructors debrief with learners, as recommended by the CPS, though only half have had training in debriefing. The results of this study support further investigation into the optimal type of simulation in NRP teaching and more formal education in simulation and debriefing for NRP instructors.

Cost Burden of Raising A Child with Fetal Alcohol Spectrum Disorder

BACKGROUND: In Canada the incidence of Fetal Alcohol Spectrum Disorder (FASD) is estimated to be 1 in 100 live births. FASD is the leading cause of developmental and cognitive disabilities in Canada. No study has examined the cost to parents/caregivers of raising a child with FASD in Canada.

OBJECTIVES: To calculate an estimate of direct and indirect costs associated with raising a child with FASD at the patient level.

DESIGN/METHODS: Cross-sectional study design was used. Two-hundred and thirty (230) participants completed the study tool. Participants included caregivers of children from day of birth to 18 years of age, living in urban and rural communities throughout Canada. Participants completed the Health Services Utilization Inventory (HSUI). Key cost components were elicited: direct costs: medical, education, social services, out-of-pocket costs; and indirect costs: productivity losses. Total average costs per individual with FASD were calculated by summing the costs in each cost component, and dividing by the sample size. Costs were extrapolated to one year. A stepwise multiple regression analysis was used to identify significant determinants of costs and to calculate the adjusted annual costs of raising a child with FASD.

RESULTS: Total adjusted annual costs associated with FASD at the individual level was $31, 640 (95% CI $25,342; $38,642). Severity of the child’s condition, age, and relationship of the individual to the caregiver (biological, adoptive, kinship) were significant determinants of costs (p < 0.001). Thirty-two (32) percent of the total costs were paid by families caring for the children: The total annual cost to parent(s)/caregiver(s) of a child with FASD was $10,124.80. These costs were beyond the costs of raising a healthy child and only associated with costs of FASD.

CONCLUSION: Study results demonstrated thecost burden of FASD in Canada to parents/caregivers. Implications to practice, policy, and research are discussed.

Early Onset Neonatal Sepsis in Canada: 2011-2012

BACKGROUND: Canadian and US studies suggest that the organisms responsible for early-onset neonatal sepsis (EONS) are changing, with an increase in Escherichia coli (EC) as well as antibiotic-resistant organisms. Current Canadian guidelines for prevention and treatment of EONS are based on Group B streptococcus (GBS) as the likely organism. Population-level data may inform updates to these national strategies.

OBJECTIVES: To determine the incidence, types of organisms and corresponding resistance patterns involved in EONS in Canada. To identify how the organisms are affected by maternal antibiotic prophylaxis and other factors.

DESIGN/METHODS: Cases of EONS (defined as positive blood and/or cerebrospinal fluid (CSF) culture at <7 days of age) between January 2011 and December 2012 were identified through the Canadian Paediatric Surveillance Program (CPSP). Neonates were excluded if they were asymptomatic with a positive culture likely to be a contaminant, or if the CSF culture was positive as a result of an intracranial procedure.

RESULTS: Over the 2-year period, 127 cases meeting our criteria were identified, and there were 754,849 total Canadian live births. The incidence for EONS was 0.17/1000 live births. 79.5% of cases presented within the first 24 hours of life, while 15% presented between 72 h-7 days. GBS accounted for 41.7% of cases, while EC accounted for 35.4%. Resistance was noted in 33.9% of cases overall. 55.6% of EC were resistant, with ampicillin resistance being the most common. The species of infecting organism was significantly associated with gestational age, very low birth weight, age at presentation, the mother having received GBS prophylaxis, and rupture of membranes lasting more than 18 h. GBS was most common in term and EC in preterm neonates. The overall EONS case fatality rate was 11%, with most of these being deaths from EC.

CONCLUSION: Our study suggests a lower rate of EONS than historically suggested, with differing dominant organisms based on gestational ages of the neonates. Later ages at presentation and high rates of resistance especially among EC cases further complicate the picture. We recommend a review of the Canadian prevention and treatment guidelines based on our findings.

Dengue virus-infected human dendritic cells reveal hierarchies of naturally expressed novel NS3 CD8 T cell epitopes

Detailed knowledge of dengue virus (DENV) cell-mediated immunity is limited. In this study we characterize CD8(+) T lymphocytes recognizing three novel and two known non-structural protein 3 peptide epitopes in DENV-infected dendritic cells. Three epitopes displayed high conservation (75-100%), compared to the others (0-50%). A hierarchy ranking based on magnitude and polyfunctionality of the antigen-specific response showed that dominant epitopes were both highly conserved and cross-reactive against multiple DENV serotypes. These results are relevant to DENV pathogenesis and vaccine design.

Molecular classifiers for acute kidney transplant rejection in peripheral blood by whole genome gene expression profiling

There are no minimally invasive diagnostic metrics for acute kidney transplant rejection (AR), especially in the setting of the common confounding diagnosis, acute dysfunction with no rejection (ADNR). Thus, though kidney transplant biopsies remain the gold standard, they are invasive, have substantial risks, sampling error issues and significant costs and are not suitable for serial monitoring. Global gene expression profiles of 148 peripheral blood samples from transplant patients with excellent function and normal histology (TX; n = 46), AR (n = 63) and ADNR (n = 39), from two independent cohorts were analyzed with DNA microarrays. We applied a new normalization tool, frozen robust multi-array analysis, particularly suitable for clinical diagnostics, multiple prediction tools to discover, refine and validate robust molecular classifiers and we tested a novel one-by-one analysis strategy to model the real clinical application of this test. Multiple three-way classifier tools identified 200 highest value probesets with sensitivity, specificity, positive predictive value, negative predictive value and area under the curve for the validation cohort ranging from 82% to 100%, 76% to 95%, 76% to 95%, 79% to 100%, 84% to 100% and 0.817 to 0.968, respectively. We conclude that peripheral blood gene expression profiling can be used as a minimally invasive tool to accurately reveal TX, AR and ADNR in the setting of acute kidney transplant dysfunction.

The emerging molecular architecture of schizophrenia, polygenic risk scores and the clinical implications for GxE research

Schizophrenia is a devastating mental disorder. The level of risk in the general population is sustained by the persistence of social, environmental and biological factors, as well as their interactions. Socio-environmental risk factors for schizophrenia are well established and robust. The same can belatedly be said of genetic risk factors for the disorder. Recent progress in schizophrenia genetics is primarily fuelled by genome-wide association, which is able to leverage substantial proportions of additional explained variance previously classified as 'missing'. Here, we provide an outline of the emerging genetic landscape of schizophrenia and demonstrate how this knowledge can be turned into a simple empirical measure of genetic risk, known as a polygenic risk score. We highlight the statistical framework used to assess the clinical potential of the new score and finally, draw relevance to and discuss the clinical implications for the study of gene-environment interaction.

Partitioning the heritability of Tourette syndrome and obsessive compulsive disorder reveals differences in genetic architecture

The direct estimation of heritability from genome-wide common variant data as implemented in the program Genome-wide Complex Trait Analysis (GCTA) has provided a means to quantify heritability attributable to all interrogated variants. We have quantified the variance in liability to disease explained by all SNPs for two phenotypically-related neurobehavioral disorders, obsessive-compulsive disorder (OCD) and Tourette Syndrome (TS), using GCTA. Our analysis yielded a heritability point estimate of 0.58 (se = 0.09, p = 5.64e-12) for TS, and 0.37 (se = 0.07, p = 1.5e-07) for OCD. In addition, we conducted multiple genomic partitioning analyses to identify genomic elements that concentrate this heritability. We examined genomic architectures of TS and OCD by chromosome, MAF bin, and functional annotations. In addition, we assessed heritability for early onset and adult onset OCD. Among other notable results, we found that SNPs with a minor allele frequency of less than 5% accounted for 21% of the TS heritability and 0% of the OCD heritability. Additionally, we identified a significant contribution to TS and OCD heritability by variants significantly associated with gene expression in two regions of the brain (parietal cortex and cerebellum) for which we had available expression quantitative trait loci (eQTLs). Finally we analyzed the genetic correlation between TS and OCD, revealing a genetic correlation of 0.41 (se = 0.15, p = 0.002). These results are very close to previous heritability estimates for TS and OCD based on twin and family studies, suggesting that very little, if any, heritability is truly missing (i.e., unassayed) from TS and OCD GWAS studies of common variation. The results also indicate that there is some genetic overlap between these two phenotypically-related neuropsychiatric disorders, but suggest that the two disorders have distinct genetic architectures.

Cozen's phenomenon: a reminder

A four-year-old child attended Accident and Emergency following a fall from a slide with a displaced and angulated proximal tibial metaphyseal fracture. Treatment included closed manipulation under anaesthesia and an above knee cast for seven weeks. Serial radiographs over the following few months were satisfactory demonstrating good alignment and evidence of healing. However, at four-months review new-onset genu valgum with mechanical axis deviation was noted. No evidence of spontaneous resolution was noted over the following 12 months and hence a corrective hemi-epiphysiodesis was performed. At 12-months post-operatively, there was marked clinical and radiographical improvement in alignment. Classically Cozen's phenomenon is described as the late-onset post-traumatic valgus deformity associated with proximal tibial metaphyseal fractures in children. We want to reemphasise the early recognition of children at risk of this unique complication. In addition, we wish to highlight the progression of the late-onset valgus and its subsequent management.