Improved antenatal detection of congenital anomalies in women with pre-gestational diabetes: population-based cohort study

AIMS

To compare antenatal detection of congenital anomaly in women with and without pre-gestational diabetes and their pregnancy outcomes in a regional cohort study.

METHODS

Data from a total of 7148 singleton pregnancies with a congenital anomaly delivered between 1 January 1996 and 31 December 2008 were extracted from the Northern Diabetes in Pregnancy and Northern Congenital Abnormality Surveys. Antenatal ultrasound detection rates of congenital anomaly in pregnancies complicated by major non-chromosomal congenital anomaly and resulting in live birth, stillbirth, late miscarriage (20-23 weeks of gestation) or termination of pregnancy for a congenital anomaly, were compared between women with and without diabetes (120 and 7028, respectively).

RESULTS

A significantly higher rate of antenatal detection of congenital anomalies was observed in women with diabetes compared with women without diabetes (50.8 vs. 38.6%, respectively; relative risk 1.32; 95% CI 1.10-1.57; P = 0.003). Cardiovascular anomalies were the only group with a significantly higher antenatal detection rate in women with diabetes (31.8 vs. 10.4%; relative risk 3.05; 95% CI 1.95-4.76; P < 0.00001). This difference remained after excluding cases of ventricular septal defect (52.2 vs. 16.3%; relative risk 3.20; 95% CI 2.13-4.80; P < 0.0001). Among women with diabetes, male fetal sex was the only factor associated with a higher antenatal detection rate. There were no differences in the rates of termination of pregnancy, late miscarriage, stillbirth or infant death between groups.

CONCLUSIONS

Antenatal detection of cardiovascular anomalies was higher in women with diabetes, suggesting that recommendations for enhanced cardiovascular scanning may improve detection. Greater awareness of the increased risk of anomalies in other organ systems is needed.

Action on the social determinants of health

Closing the Gap in a Generation, the final report of the Commission on Social Determinants of Health (CSDH) proposed that inequities in power, money and resources were responsible for much of the inequalities in health within and between countries. A toxic combination of poor policies and programmes, unfair economic arrangements and bad governance led to inequalities in the conditions of daily life: the circumstances in which people are born, grow, live, work, and age. Our message is that there needs to be a cross-government commitment to action on social determinants of health. With this commitment, the knowledge synthesised in our report suggests that there is much that can be done at the practical level.

Preventing type 2 diabetes after gestational diabetes: women's experiences and implications for diabetes prevention interventions

AIMS

To explore factors influencing post-natal health behaviours following the experience of gestational diabetes, and to elicit women's views about the feasibility of lifestyle intervention to prevent diabetes during the first 2 years after childbirth.

METHODS

Qualitative study using semi-structured interviews with women who had gestational diabetes. In phase 1 (31 women), interviews explored the experience of gestational diabetes, ideas about future risk of diabetes and factors influencing post-natal health-related behaviours. Statements were developed summarizing women's views of lifestyle change to prevent diabetes. In phase 2 (14 women), interviews explored how the passage of time had contributed to changes in health behaviour, and the statements were used to develop views about diabetes interventions.

RESULTS

Women were aware of their risk of developing diabetes, but did not always act on such knowledge. Pregnancy motivated behaviour changes to benefit the unborn child, but after delivery these changes were often not maintained. Tiredness, maternal attachment and childcare demands were prominent barriers in the early post-natal months. Later, work, family and child development became more significant barriers. Many women became more receptive to healthy eating messages around the time of weaning. Women were positive about long-term support for self-management to reduce their diabetes risk.

CONCLUSIONS

There is potential to reduce the risk of Type 2 diabetes post-natally among women with gestational diabetes. Interventions need to be developed that take into account contextual factors and competing demands, are flexible and respond to women's individual circumstances. Randomized trials of such interventions are warranted.

Universal screening to identify gestational diabetes: a multi-centre study in the North of England

We conducted an audit of treatment and outcomes in 116 women with gestational diabetes. These women received intense monitoring and high levels of medical and obstetric intervention. 24% would not have been identified by risk factor based screening. Cost effective strategies to identify all women with gestational diabetes are needed.

Abstract P5-18-02: Selective Crossover in Randomized Trials of Adjuvant Trastuzumab for Breast Cancer: Coping with Success

BACKGROUND: Disease-free survival (DFS) is often a primary endpoint of randomized trials of adjuvant therapies for breast cancer, but long-term follow-up of DFS and especially overall survival (OS) remain important. When the primary DFS results favor the experimental arm, patients (pts) assigned to the control group may select the option to crossover to receive the experimental treatment via protocol amendment. Such “selective crossover” disturbs the integrity of the randomized comparison for any efficacy endpoints that rely on further follow-up. Selective crossover, which is motivated by positive results having been observed in the current trial, is distinct from so-called “unplanned crossover,” which refers to non-adherence to protocol. In this abstract, we discuss the consequences of selective crossover for trials evaluating adjuvant trastuzumab, using the HERA (HERceptin Adjuvant) trial as an example, and present a variety of alternative analysis approaches.

METHODS: HERA enrolled 5102 women with HER2-positive early breast cancer who had completed all surgery and (neo)adjuvant chemotherapy to compare 1 or 2 years of trastuzumab treatment vs observation. After a positive first interim analysis at 1y median follow-up (MFU) showed that 1 year of trastuzumab significantly improved DFS vs observation [MJ Piccart-Gebhart et al; NEJM 2005], event-free patients in the observation group were offered crossover to receive trastuzumab. 885 (52%) of the 1698 pts in the observation group selectively crossed over to trastuzumab.

RESULTS: Previously reported intention-to-treat (ITT) analysis of HERA at 4y MFU showed a decreasing effectiveness of trastuzumab with respect to DFS compared with those at 2y MFU [L Gianni et al, Lancet Oncol 2011; I Smith et al, Lancet 2007]. In addition, the ITT analysis of OS at 4y MFU showed little effect of trastuzumab, while the analysis artificially censoring follow-up in the observation group at the time of selective crossover showed a substantial OS advantage for trastuzumab.

Abstract P3-06-34: Plasma (p) VEGF-A and VEGFR-2 biomarker (BM) results from the BEATRICE phase III trial of bevacizumab (BEV) in triple-negative early breast cancer (BC)

Background: Several candidate BMs have been explored in randomized trials of BEV across tumor types with the aim of identifying patients (pts) deriving the most substantial benefit from BEV therapy. In phase III trials, baseline pVEGF-A and pVEGFR-2 showed potential predictive value in metastatic BC (AVADO, AVEREL), pancreatic cancer (AViTA), and gastric cancer (AVAGAST; VEGF-A only). The randomized phase III BEATRICE trial, evaluating the addition of BEV to adjuvant chemotherapy in pts with triple-negative early BC, includes a comprehensive program to identify potential BMs predicting efficacy and toxicity of BEV therapy. We report results for baseline pVEGF-A and pVEGFR-2.

Methods: After selection of chemotherapy (anthracycline and/or taxane), pts with T1a-T3 operable BC were randomized 1:1 to receive ≥4 cycles of chemotherapy either alone or with 1 year of BEV 5 mg/kg/wk equivalent. The primary endpoint is invasive disease-free survival (IDFS). pEDTA samples were collected from consenting pts at baseline (before treatment, after surgery), during study treatment, and at relapse. Pts were dichotomized using the median baseline concentration of each marker as the cut-off between high and low cohorts; further exploratory analyses were also performed by quartile.

Results: Between Dec 2007 and Mar 2010, 2591 pts were enrolled. Of these, 1273 (49%) consented to the BM study and 1178 (45%) were included in the BM-evaluable population (BEP). Overall, the BEP was representative of the ITT population except for lower proportions of Asian pts (12% vs 24%). IDFS was similar in the BEP and ITT populations. Baseline characteristics were balanced between arms in the BEP. Baseline pVEGF-A showed neither prognostic nor predictive value using the median as the cut-off, although with a third quartile (Q3) cut-off there was a more pronounced but non-significant differentiation between treatments (HR 0.92 [low] vs 0.64 [high]). High baseline pVEGFR-2 showed potential predictive value for BEV efficacy (HR 1.24 [low] vs 0.61 [high]; p=0.029).

HbA(1c) and birthweight in women with pre-conception type 1 and type 2 diabetes: a population-based cohort study

AIMS/HYPOTHESIS

To investigate clinical and sociodemographic predictors of birthweight in singletons born to women with type 1 or type 2 diabetes.

METHODS

Normally formed singleton live births and intrapartum stillbirths, born to women with pre-conception diabetes during 1996-2008, were identified from the population-based Northern Diabetes in Pregnancy Survey (n = 1,505). Associations between potential predictors and birthweight were analysed by multiple regression.

RESULTS

Potentially modifiable independent predictors of increase in birthweight were pre-pregnancy care (adjusted regression coefficient [b] = 87.1 g; 95% CI 12.9, 161.3), increasing third-trimester HbA(1c) ≤7% (53 mmol/mol) (b = 310.5 g per 1% [11 mmol/mol]; 95% CI 246.3, 374.7) and increasing maternal BMI (b = 9.5 g per 1 kg/m(2); 95% CI 3.5, 15.5). Smoking during pregnancy (b = -145.1 g; 95% CI -231.4, -58.8), later gestation at first antenatal visit (b = -15.0 g; 95% CI -26.9, -3.0) and higher peri-conception HbA(1c) (b = -48.2 g; 95% CI -68.8, -27.6) were independently associated with birthweight reduction. Pre-pregnancy nephropathy (b = -282.7 g; 95% CI -461.8, -103.6) and retinopathy (b = -175.5 g; 95% CI -269.9, -81.0) were independent non-modifiable predictors of reduced birthweight, while greater maternal height was a non-modifiable predictor of increasing birthweight (b = 17.8 g; 95% CI 12.3, 23.2). Other predictors of birthweight increase were male sex, multiparity and increasing gestational age at delivery. Type or duration of diabetes, socioeconomic status and ethnicity were not associated with continuous birthweight.

CONCLUSIONS/INTERPRETATION

Poor glycaemic control before and throughout pregnancy is associated with abnormal fetal growth, with increasing peri-conception HbA(1c) predicting weight reduction and increasing third-trimester HbA(1c) predicting increased birthweight. Women with microvascular complications of diabetes may require increased surveillance to detect fetal growth restriction.

Mechanism and relevance of EWS/FLI-mediated transcriptional repression in Ewing sarcoma

Ewing sarcoma provides an important model for transcription-factor mediated oncogenic transformation because of its reliance on the ETS-type fusion oncoprotein EWS/FLI. EWS/FLI functions as a transcriptional activator and transcriptional activation is required for its oncogenic activity. Here we demonstrate that a previously less-well characterized transcriptional repressive function of the EWS/FLI fusion is also required for the transformed phenotype of Ewing sarcoma. Through comparison of EWS/FLI transcriptional profiling and genome-wide localization data, we define the complement of EWS/FLI direct downregulated target genes. We demonstrate that LOX is a previously undescribed EWS/FLI-repressed target that inhibits the transformed phenotype of Ewing sarcoma cells. Mechanistic studies demonstrate that the NuRD co-repressor complex interacts with EWS/FLI, and that its associated histone deacetylase and LSD1 activities contribute to the repressive function. Taken together, these data reveal a previously unknown molecular function for EWS/FLI, demonstrate a more highly coordinated oncogenic transcriptional hierarchy mediated by EWS/FLI than previously suspected, and implicate a new paradigm for therapeutic intervention aimed at controlling NuRD activity in Ewing sarcoma tumors.

Women's perception of future risk following pregnancies complicated by preeclampsia

OBJECTIVE

To elicit women's personal understanding of future cardiovascular risk, following a pregnancy complicated by preeclampsia, and to identify the postnatal needs of these women.

METHODS

Semi-structured interviews with 12 women with a recent history of preeclampsia who had attended a postnatal follow-up clinic.

RESULTS

The interviews were held at a median of 47 weeks postpartum (range 24-62 weeks). Family history of cardiovascular disease was associated with a greater awareness of future cardiovascular risk. Women without traditional risk factors found it hard to envisage themselves as being at risk and may not see the relevance of such information. It may take several months after delivery for a woman to be able to fully consider her own health as well as the baby's; a reminder of risk and health information is needed.

CONCLUSIONS

Although receptive to follow-up, the situational factors of being a new mother need to be taken into account to engage successfully with this patient group. Further research is needed to help clarify the extent to which a history of preeclampsia is an independent factor for future cardiovascular disease to provide a solid foundation for effective risk communication.