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Martinez NCM, de Almeida ST, Rosa RFM, Zen PRG. Prevalence and clinical characterization of oral clefts in patients with chromosome trisomy 18. REVISTA PAULISTA DE PEDIATRIA : ORGAO OFICIAL DA SOCIEDADE DE PEDIATRIA DE SAO PAULO 2024; 42:e2023169. [PMID: 38922187 PMCID: PMC11197772 DOI: 10.1590/1984-0462/2024/42/2023169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 02/18/2024] [Indexed: 06/27/2024]
Abstract
OBJECTIVE To verify the prevalence and perform the clinical characterization of oral clefts in a sample of patients with trisomy of chromosome 18 in Southern Brazil. METHODS This was a retrospective cross-sectional study, performed in a reference clinical genetic service in Southern Brazil. The initial sample consisted of 77 patients diagnosed in the neonatal period with trisomy 18 treated at the Clinical Genetics Service of a referral hospital at Federal University of Health Sciences of Porto Alegre (UFCSPA). The patients' diagnosis was confirmed by karyotype and care was provided during their stay in the intensive care unit (ICU) of the hospital that is a reference in Southern Brazil for care for malformed patients. The period covered was from 1975 to 2020. RESULTS During the study period, 77 patients diagnosed with trisomy 18 were treated, most of them in the ICU. Of these, 13 individuals were excluded due to incomplete data. The final sample consisted of 64 patients with an average age of 2.4 years of life, ranging from one day to 16 years old, the majority of whom were female. Regarding face dysmorphisms identified in the sample, three (4,68%) patients had cleft lip and two (3,11%) had cleft lip and palate. CONCLUSIONS This study contributed to the recognition of the characteristics and prevalence of oral clefts in individuals with trisomy 18 in a sample of patients from Southern Brazil. In addition, we described the clinical alterations found in patients with oral clefts, as well as other associated comorbidities, such as cardiac, neurological and pulmonary comorbidities, as well as cranial and facial dysmorphisms.
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Affiliation(s)
| | - Sheila Tamanini de Almeida
- Universidade Federal de Ciências da Saúde de Porto Alegre – Porto Alegre, RS, Brazil
- Irmandade da Santa Casa de Misericórdia de Porto Alegre – Porto Alegre, RS, Brazil
| | - Rafael Fabiano Machado Rosa
- Universidade Federal de Ciências da Saúde de Porto Alegre – Porto Alegre, RS, Brazil
- Irmandade da Santa Casa de Misericórdia de Porto Alegre – Porto Alegre, RS, Brazil
| | - Paulo Ricardo Gazzola Zen
- Universidade Federal de Ciências da Saúde de Porto Alegre – Porto Alegre, RS, Brazil
- Irmandade da Santa Casa de Misericórdia de Porto Alegre – Porto Alegre, RS, Brazil
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Marçola L, Zoboli I, Polastrini RTV, Barbosa SMDM, Falcão MC, Gaiolla PDV. Patau and Edwards Syndromes in a University Hospital: beyond palliative care. REVISTA PAULISTA DE PEDIATRIA : ORGAO OFICIAL DA SOCIEDADE DE PEDIATRIA DE SAO PAULO 2023; 42:e2023053. [PMID: 38088680 PMCID: PMC10712940 DOI: 10.1590/1984-0462/2024/42/2023053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 09/15/2023] [Indexed: 12/17/2023]
Abstract
OBJECTIVE To describe the newborn population with Patau (T13) and Edwards Syndrome (T18) with congenital heart diseases that stayed in the Intensive Care Unit (ICU) of a quaternary care hospital complex, regarding surgical and non-surgical medical procedures, palliative care, and outcomes. METHODS Descriptive case series conducted from January/2014 to December/2018 through analysis of records of patients with positive karyotype for T13 or T18 who stayed in the ICU of a quaternary hospital. Descriptive statistics analysis was applied. RESULTS 33 records of eligible patients were identified: 27 with T18 (82%), and 6 T13 (18%); 64% female and 36% male. Eight were preterm infants with gestational age between 30-36 weeks (24%), and only 4 among the 33 infants had a birth weight >2500 g (12%). Four patients underwent heart surgery and one of them died. Intrahospital mortality was 83% for T13, and 59% for T18. The majority had other malformations and underwent other surgical procedures. Palliative care was offered to 54% of the patients. The median hospitalization time for T18 and T13 was 29 days (range: 2-304) and 25 days (13-58), respectively. CONCLUSIONS Patients with T13 and T18 have high morbidity and mortality, and long hospital and ICU stays. Multicentric studies are needed to allow the analysis of important aspects for creating protocols that, seeking therapeutic proportionality, may bring better quality of life for patients and their families.
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Affiliation(s)
- Ligia Marçola
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brazil
| | - Ivete Zoboli
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brazil
| | | | | | - Mário Cícero Falcão
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brazil
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Koshida S, Takahashi K. Significant improvement in survival outcomes of trisomy 18 with neonatal intensive care compared to non-intensive care: a single-center study. PeerJ 2023; 11:e16537. [PMID: 38047023 PMCID: PMC10693230 DOI: 10.7717/peerj.16537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/07/2023] [Indexed: 12/05/2023] Open
Abstract
Background Trisomy 18 syndrome, also known as Edwards syndrome, is a chromosomal trisomy. The syndrome has historically been considered lethal owing to its poor prognosis, and palliative care was primarily indicated for trisomy 18 neonates. Although there have been several reports on the improvement of survival outcomes in infants with trisomy 18 syndrome through neonatal intensive care, few studies have compared the impact of neonatal intensive care on survival outcomes with that of non-intensive care. Therefore, we compared the survival-related outcomes of neonates with trisomy 18 between intensive and non-intensive care. Methods Seventeen infants of trisomy 18 admitted to our center between 2007 and 2019 were retrospectively studied. We divided the patients into a non-intensive group (n = 5) and an intensive group (n = 12) and evaluated their perinatal background and survival-related outcomes of the two groups. Results The 1- and 3-year survival rates were both 33% in the intensive group, which was significantly higher than that in the non-intensive group (p < 0.001). Half of the infants in the intensive care group were discharged alive, whereas in the non-intensive care group, all died during hospitalization (p = 0.049). Conclusions Neonatal intensive care for neonates with 18 trisomy significantly improved not only survival rates but also survival-discharge rates. Our findings would be helpful in providing 18 trisomy neonates with standard neonatal intensive care when discussing medical care with their parents.
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Affiliation(s)
- Shigeki Koshida
- Perinatal Center, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu, Shiga, Japan
| | - Kentaro Takahashi
- Perinatal Center, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu, Shiga, Japan
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Takai A, Yamagishi M, Ikeda K, Sugimoto A, Ichise E, Maeda Y, Teramukai S, Hasegawa T, Oda S, Iehara T. Effectiveness of cardiac palliative surgery for trisomy 18 patients with increased pulmonary blood flow. Am J Med Genet A 2023; 191:2703-2710. [PMID: 37698299 DOI: 10.1002/ajmg.a.63401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/25/2023] [Accepted: 08/30/2023] [Indexed: 09/13/2023]
Abstract
Congenital heart disease (CHD) is common among patients with trisomy 18 (T18), but cardiac surgery has been rarely indicated for T18 patients due to their short life span. Although the therapeutic effects of aggressive interventions were recently demonstrated for T18 patients, the subjects and factors examined varied, resulting in inconsistent findings. Therefore, the effects of cardiac surgery for T18 remain unclear. We herein investigated the outcomes of cardiac palliative surgery for CHD with increased pulmonary blood flow in T18 patients. 27 patients were examined: 13 (48.1%) underwent cardiac palliative surgery and 14 (51.9%) did not. Median survival times in the no-surgery and surgery groups were 223.0 days (95% confidence interval [CI]: 46-361 days) and 723.0 days (95% CI: 360-1447 days), respectively. The number of patients with pulmonary hypertension significantly differed between the two groups (5 of 14 in the no-surgery group and 0 in the surgery group). Five of 14 patients in the no-surgery group and 10 of 13 in the surgery group were discharged to home care (odds ratio: 10.8 [95% CI: 1.07-110.0]). Therefore, cardiac palliative surgery may be used to treat CHD with increased pulmonary blood flow in T18 patients.
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Affiliation(s)
- Akari Takai
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Pediatrics, Hananoki Medical Welfare Center, Kyoto, Japan
| | - Masaaki Yamagishi
- Department of Pediatric Cardiovascular Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kazuyuki Ikeda
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Atsuya Sugimoto
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Neonatology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Eisuke Ichise
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Pediatrics, National Hospital Organization Maizuru Medical Center, Kyoto, Japan
| | - Yoshinobu Maeda
- Department of Pediatric Cardiovascular Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tatsuji Hasegawa
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shinichiro Oda
- Department of Pediatric Cardiovascular Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomoko Iehara
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Kosiv KA, Mercurio MR, Carey JC. The common trisomy syndromes, their cardiac implications, and ethical considerations in care. Curr Opin Pediatr 2023; 35:531-537. [PMID: 37551160 DOI: 10.1097/mop.0000000000001278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
PURPOSE OF REVIEW To review the incidence of congenital heart disease in the trisomies, highlight the history of cardiac surgery in trisomy 21 comparing it to the increase in cardiac surgery in trisomies 13 and 18, discuss ethical issues specific to trisomies 13 and 18, and suggest a pathway of shared decision-making in the management of congenital heart disease in trisomy 13 and 18, specifically congenital heart surgery. RECENT FINDINGS Congenital heart disease is prevalent in the trisomies and the management of these defects, especially surgical intervention, has changed. In the late 20th century, survival after cardiac surgery in trisomy 21 vastly improved, significantly decreasing morbidity and mortality secondary to pulmonary hypertension. Similarly, procedures and surgeries have been performed with increasing frequency in trisomy 13 and 18 patients and concomitantly, survival in this patient population is increasing. Yet across the United States, the willingness to perform cardiac surgery in trisomy 13 and 18 is variable, and there is ethical controversy about the correct action to take. To address this concern, a shared decision-making approach with an informed parent(s) is advised. SUMMARY As the care and management of congenital heart disease changed in trisomy 21, so too it has with trisomy 13 and 18. Physicians and parents should develop goal-directed treatment plans balancing the risk versus benefit and consider cardiac surgical repair if feasible and beneficial.
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Swanson SK, Schumacher KR, Ohye RG, Zampi JD. Impact of trisomy 13 and 18 on airway anomalies and pulmonary complications after cardiac surgery. J Thorac Cardiovasc Surg 2021; 162:241-249. [DOI: 10.1016/j.jtcvs.2020.08.082] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 08/16/2020] [Accepted: 08/21/2020] [Indexed: 11/28/2022]
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Redefining the Relationship: Palliative Care in Critical Perinatal and Neonatal Cardiac Patients. CHILDREN-BASEL 2021; 8:children8070548. [PMID: 34201973 PMCID: PMC8304963 DOI: 10.3390/children8070548] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/24/2021] [Accepted: 06/08/2021] [Indexed: 12/02/2022]
Abstract
Patients with perinatal and neonatal congenital heart disease (CHD) represent a unique population with higher morbidity and mortality compared to other neonatal patient groups. Despite an overall improvement in long-term survival, they often require chronic care of complex medical illnesses after hospital discharge, placing a high burden of responsibility on their families. Emerging literature reflects high levels of depression and anxiety which plague parents, starting as early as the time of prenatal diagnosis. In the current era of the global COVID-19 pandemic, the additive nature of significant stressors for both medical providers and families can have catastrophic consequences on communication and coping. Due to the high prognostic uncertainty of CHD, data suggests that early pediatric palliative care (PC) consultation may improve shared decision-making, communication, and coping, while minimizing unnecessary medical interventions. However, barriers to pediatric PC persist largely due to the perception that PC consultation is indicative of “giving up.” This review serves to highlight the evolving landscape of perinatal and neonatal CHD and the need for earlier and longitudinal integration of pediatric PC in order to provide high-quality, interdisciplinary care to patients and families.
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Nakai R, Fujioka T, Okamura K, Suzuki T, Nakao A, Kobayashi J, Tsuchiya K. Survival Outcomes of Two-Stage Intracardiac Repair in Large Ventricular Septal Defect and Trisomy 18. Pediatr Cardiol 2021; 42:821-831. [PMID: 33515091 DOI: 10.1007/s00246-021-02546-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 01/05/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Surgical management has not been encouraged in patients with trisomy 18 (T18) and congenital heart diseases due to poor survival. This study aimed to investigate (1) the appropriateness of palliative surgeries followed by intracardiac repair (ICR) (i.e., two-stage ICR) for patients with a large ventricular septal defect (VSD) and T18, and (2) its impact on their long-term outcomes. METHODS Medical charts of patients with VSD and T18 who underwent two-stage ICR at the Japanese Red Cross Medical Center between January 2005 and December 2019 were retrospectively reviewed. Demographic data, timing, and types of palliative surgeries, information related to ICR, peri- and postoperative clinical information, postoperative survival, and cause of death were collected. The long-term prognosis of patients treated with two-stage ICR was compared with that of patients treated with primary ICR and palliative surgery without ICR. RESULTS Overall, 18 (2 male, 16 female) patients underwent two-stage ICR. Pulmonary artery banding was the initial palliative surgery in all patients after a median duration of 19.5 (range 6-194) days of life. The median age and the mean body weight at the time of ICR were 18.2 (7.6-50.7) months and 6.0 ± 1.0 kg, respectively. The mean pulmonary artery pressure and pulmonary vascular resistance index before ICR were 19.1 ± 7.3 mmHg and 3.4 ± 2.0 U m2, respectively. Overall, 17/18 (94%) patients were discharged after ICR. Fourteen (78%) patients were alive during data collection. None of the patients died of cardiac insufficiency, and the median duration of survival was 46.3 (14.3-186.4) months since birth. Most patients required cardiac medications rather than pulmonary vasodilators at the last follow-up. During the study period, three patients underwent primary ICR, and 46 underwent palliative surgery without ICR. Of those who underwent primary ICR, two died in the hospital on the first and 48th day following ICR, and the third died 179 days after the ICR. The Log-rank test revealed a significantly longer survival for the patients treated with two-stage ICR compared with those treated with palliative surgery without ICR (P = 0.003). CONCLUSION Two-stage ICR improves the long-term survival of patients with VSDs and T18. This safe surgical strategy can also prevent pulmonary hypertension in such patients.
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Affiliation(s)
- Ryosuke Nakai
- Department of Pediatrics, Japanese Red Cross Medical Center, 4-1-22, Hiroo, Shibuya-ku, Tokyo, 150-8935, Japan
| | - Tao Fujioka
- Department of Pediatrics, Japanese Red Cross Medical Center, 4-1-22, Hiroo, Shibuya-ku, Tokyo, 150-8935, Japan.
| | - Kenichi Okamura
- Department of Cardiovascular Surgery, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Toshihiko Suzuki
- Department of Cardiovascular Surgery, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Atsushi Nakao
- Department of Neonatology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Jotaro Kobayashi
- Department of Cardiovascular Surgery, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Keiji Tsuchiya
- Department of Pediatrics, Japanese Red Cross Medical Center, 4-1-22, Hiroo, Shibuya-ku, Tokyo, 150-8935, Japan
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Suto M, Isayama T, Morisaki N. Population-Based Analysis of Secular Trends in Age at Death in Trisomy 18 Syndrome in Japan from 1975 to 2016. Neonatology 2021; 118:47-53. [PMID: 33486488 DOI: 10.1159/000512922] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/07/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Despite changes in prenatal diagnostic methods and perceptions regarding the prognosis of and treatment options for patients with trisomy 18 syndrome, data on the secular changes in patient survival are limited. This study aimed to investigate the survival pattern for such patients. METHODS To investigate the general patient survival patterns, we used data from the vital statistics database of deaths in Japan from 1975 to 2016. We described demographic factors, such as sex, gestational age at delivery, and surgical history, for patients whose primary cause of death was trisomy 18 syndrome. RESULTS The proportions of deaths within 24 h of birth (4.0% in 1975-1980 to 21.9% in 2011-2016) and at age ≥1 year (8.9% in 1975-1980 to 17.7% in 2011-2016) increased. The median survival time was higher for females, infants born after 37 weeks of gestation, and those who received surgical intervention. The median survival time tripled among patients who received surgical intervention (61.5 days in 1995-2005 to 182.5 days in 2006-2016), and the proportion of such patients increased (from 3.8% in 1995 to 24.1% of the entire affected population in 2016). DISCUSSION/CONCLUSION In Japan, the median survival time of infants with trisomy 18 increased over time, and the proportion of death within 24 h and at ≥1 year increased. Greater acknowledgement of the possible benefits of surgical intervention likely led to the increased provision of interventions and contributed to the increased survival time.
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Affiliation(s)
- Maiko Suto
- Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan
| | - Tetsuya Isayama
- Division of Neonatology, National Center for Child Health and Development, Tokyo, Japan
| | - Naho Morisaki
- Department of Social Medicine, National Center for Child Health and Development, Tokyo, Japan,
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Milligan MCP, Jackson LE, Maurer SH. Clinical Course for Patients With Trisomy 13 and 18 Pursuing Life-Prolonging Therapies Versus Comfort-Directed Care. Am J Hosp Palliat Care 2020; 38:1225-1229. [PMID: 33375814 DOI: 10.1177/1049909120985210] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Care for infants with Trisomy 13 and 18 is evolving with more children being offered medical and surgical interventions. Parents and clinicians of children diagnosed with trisomy 13 and 18 would benefit from understanding how parental goals of care correlate with the subsequent clinical course of children with these conditions. OBJECTIVE To describe and compare parental goals of care (GOC) and clinical course in infants with trisomy 13 and 18. DESIGN Single center, retrospective (2013-19) analysis of electronic health record repository at a birthing center and a tertiary care hospital. MEASUREMENTS ICD-9/10 codes were used to identify patients with trisomy 13 or 18 born between 2013-2019. Their records were abstracted for their diagnosis, hospitalization days, interventions, GOC, death location and length of life. RESULT Twenty-eight total patients were identified; trisomy 13, mosaic trisomy 13 and trisomy 18 were diagnosed in 9, 2 and 17 patients respectively. Among the 26 patients with complete trisomy 13 or 18, 8 had life-prolonging and 18 had comfort care goals at birth/diagnosis. Life-prolonging goals were not associated with longer life (p = 0.36) but were associated with more mean hospital days (70 vs. 12, p = 0.01), ICU days (66 vs. 9, p = 0.009), intubation (7/8 vs 7/18, p = 0.04), and death in ICU (7/7 vs. 10/17, p = 0.02). Zero patients underwent cardiac surgery. CONCLUSION Parental GOC did not affect length of life in children with complete trisomy, but did alter treatment intensity. This may inform decision making for patients with trisomy 13 or 18.
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Affiliation(s)
- Michelle C Perry Milligan
- Department of Pediatrics, University of Pittsburgh School of Medicine, 6619UPMC Children's Hospital of Pittsburgh, PA, USA.,Department of Pediatrics, Children's Hospital of Philadelphia, PA, USA
| | - Laura E Jackson
- Department of Pediatrics, University of Pittsburgh School of Medicine, PA, USA.,Division of Newborn Medicine, 6619UPMC Children's Hospital of Pittsburgh, PA, USA
| | - Scott H Maurer
- Department of Pediatrics, University of Pittsburgh School of Medicine, 6619UPMC Children's Hospital of Pittsburgh, PA, USA.,Division of Palliative Medicine & Supportive Care, 6619UPMC Children's Hospital of Pittsburgh, PA, USA
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Carvajal HG, Callahan CP, Miller JR, Rensink BL, Eghtesady P. Cardiac Surgery in Trisomy 13 and 18: A Guide to Clinical Decision-Making. Pediatr Cardiol 2020; 41:1319-1333. [PMID: 32924070 DOI: 10.1007/s00246-020-02444-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/25/2020] [Indexed: 11/26/2022]
Abstract
There has been substantial controversy regarding treatment of congenital heart defects in infants with trisomies 13 and 18. Most reports have focused on surgical outcomes versus expectant treatment, and rarely there has been an effort to consolidate existing evidence into a more coherent way to help clinicians with decision-making and counseling families. An extensive review of the existing literature on cardiac surgery in patients with these trisomies was conducted from 2004 to 2020. The effects of preoperative and perioperative factors on in-hospital and long-term mortality were analyzed, as well as possible predictors for postoperative chronic care needs such as tracheostomy and gastrostomy. Patients with minimal or no preoperative pulmonary hypertension and mechanical ventilation undergoing corrective surgery at a weight greater than 2.5 kg suffer from lower postoperative mortality. Infants with lower-complexity cardiac defects are likely to benefit the most from surgery, although their expected mortality is higher than that of infants without trisomy. Omphalocele confers an increased mortality risk regardless of cardiac surgery. Gastrointestinal comorbidities increased the risk of gastrostomy tube placement, while those with prolonged mechanical ventilation and respiratory comorbidities are more likely to require tracheostomy. Cardiac surgery is feasible in children with trisomies 13 and 18 and can provide improved long-term results. However, this is a clinically complex population, and both physicians and caretakers should be aware of the long-term challenges these patients face following surgery when discussing treatment options.
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Affiliation(s)
- Horacio G Carvajal
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St. Louis/St. Louis Children's Hospital, Saint Louis, MO, USA
| | - Connor P Callahan
- Department of Surgery, Barnes-Jewish Hospital, Washington University School of Medicine in St. Louis, Saint Louis, MO, USA
| | - Jacob R Miller
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St. Louis/St. Louis Children's Hospital, Saint Louis, MO, USA
| | - Bethany L Rensink
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St. Louis/St. Louis Children's Hospital, Saint Louis, MO, USA
| | - Pirooz Eghtesady
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St. Louis/St. Louis Children's Hospital, Saint Louis, MO, USA.
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Haghnazarian E, Hu J, Song AY, Friedlich PS, Lakshmanan A. The association of Trisomy 13 and 18 and hospital discharge outcomes among neonates in California: A retrospective cohort study. Pediatr Neonatol 2019; 60:617-622. [PMID: 30935949 PMCID: PMC7062359 DOI: 10.1016/j.pedneo.2019.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 12/06/2018] [Accepted: 02/26/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Despite Trisomy 13 and 18 being among the most fatal congenital anomalies, limited information exists about resource utilization and factors associated with length of stay (LOS) and total hospital charges (THC) for these anomalies. METHODS We studied data sets of the patient discharge data set from the California Office of Statewide Health Planning and Development from 2006 to 2010, to determine differences in resource utilization for survivors and non-survivors and identify the predictors of LOS and total hospital charges. Descriptive statistics were assessed for demographic and clinical characteristics. General linear regression models were used to identify predictors of LOS and THC. RESULTS Seventy-six Trisomy 13 and 115 Trisomy 18 patients were identified, for whom inpatient mortality was 27.6% and 20.9%, respectively. In patients with Trisomy 13, after adjusting for gender, ethnicity, advanced directive (DNR), insurance and co-morbidities on multivariate analysis, the provision of more than 96 h of mechanical ventilation was associated with significantly increased LOS (standard error, SE) by 18.0 ± 5.3 days and THC (SE) by $399,000 ± $85,000. In terms of insurance type, patients with private coverage had 10.8 ± 4.9 days more than patients with Medicaid. In patients with Trisomy 18, on multivariate analysis, after adjusting for gender, ethnicity, DNR, insurance and co-morbidities, more than 96 h of mechanical ventilation was associated with increased LOS (SE) by 36.8 ± 6.8 days and THC (SE) by $365,000 ± $59,000. CONCLUSION Understanding predictors that are associated with longer LOS and higher THC may be associated in hospital resource allocation for this vulnerable population of infants.
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Affiliation(s)
- Edith Haghnazarian
- Fetal and Neonatal Medicine Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90027, United States
| | - Jiaqi Hu
- Fetal and Neonatal Medicine Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90027, United States
| | - Ashley Y Song
- Fetal and Neonatal Medicine Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90027, United States; Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, United States
| | - Philippe S Friedlich
- Fetal and Neonatal Medicine Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90027, United States
| | - Ashwini Lakshmanan
- Fetal and Neonatal Medicine Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90027, United States; Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, United States; Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, 90089, United States; USC Gehr Family Center for Health Systems Science, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, United States.
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13
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Kato E, Kitase Y, Tachibana T, Hattori T, Saito A, Muramatsu Y, Takemoto K, Yamamoto H, Hayashi S, Yasuda A, Kato Y, Ieda K, Oshiro M, Sato Y, Hayakawa M. Factors related to survival discharge in trisomy 18: A retrospective multicenter study. Am J Med Genet A 2019; 179:1253-1259. [DOI: 10.1002/ajmg.a.61146] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 01/26/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Eiko Kato
- Department of PediatricsTosei General Hospital Aichi Japan
| | - Yuma Kitase
- Division of Neonatology, Center for Maternal–Neonatal CareNagoya University Hospital Nagoya Japan
| | | | | | - Akiko Saito
- Division of Neonatology, Center for Maternal–Neonatal CareNagoya University Hospital Nagoya Japan
| | - Yukako Muramatsu
- Department of PediatricsCentral Hospital, Aichi Human Service Center Aichi Japan
| | - Koji Takemoto
- Department of PediatricsKonan Kosei Hospital Aichi Japan
| | - Hikaru Yamamoto
- Department of PediatricsToyota Memorial Hospital Aichi Japan
| | - Seiji Hayashi
- Department of PediatricsOkazaki City Hospital Aichi Japan
| | - Ayako Yasuda
- Department of NeonatologyJapanese Red Cross Nagoya Daiichi Hospital Nagoya Japan
| | - Yuichi Kato
- Department of PediatricsAnjo Kosei Hospital Aichi Japan
| | - Kuniko Ieda
- Department of PediatricsTosei General Hospital Aichi Japan
| | - Makoto Oshiro
- Department of NeonatologyJapanese Red Cross Nagoya Daiichi Hospital Nagoya Japan
| | - Yoshiaki Sato
- Division of Neonatology, Center for Maternal–Neonatal CareNagoya University Hospital Nagoya Japan
| | - Masahiro Hayakawa
- Division of Neonatology, Center for Maternal–Neonatal CareNagoya University Hospital Nagoya Japan
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14
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Mullin J, Wolfe J, Bluebond-Langner M, Craig F. Experiences of children with trisomy 18 referred to pediatric palliative care services on two continents. Am J Med Genet A 2019; 179:903-907. [PMID: 30932336 PMCID: PMC6766889 DOI: 10.1002/ajmg.a.61149] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 02/20/2019] [Accepted: 02/27/2019] [Indexed: 11/11/2022]
Abstract
Children with trisomy 18 that survive beyond the neonatal period have multiple congenital anomalies, neurodevelopmental disability, and high mortality rates. The experience of children with trisomy 18 who receive pediatric palliative care services is largely unknown. We conducted a retrospective review of children with trisomy 18 receiving pediatric palliative care services at both Boston Children's Hospital, USA and Great Ormond Street Hospital, UK from January 1, 2004 to January 1, 2015. Fifty-eight children with trisomy 18 were referred to pediatric palliative care, 38 in the United Kingdom, 20 in the United States. Median age at referral was 19 days (2-89) in the United Kingdom, and 25 days (1-463) in the United States. Median length of time being followed by pediatric palliative care was 32 days (1-1,637) in the United Kingdom and 67 days (3-2,442) in the United States. The only significant difference in the two cohorts (p = .001) was in likelihood of receiving cardiac surgical intervention-37% in the United States, 0% the United Kingdom. Children with trisomy 18 receive pediatric palliative care services, with variable age at referral and for a variable length of time. Further research is needed to understand the experience of children with trisomy 18 and their families receiving pediatric palliative care services.
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Affiliation(s)
- Jonathan Mullin
- Department of Pediatrics, Washington University in St Louis, St. Louis, Missouri
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Myra Bluebond-Langner
- Faculty of Population Health Sciences, Louis Dundas Centre for Children's Palliative Care, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Finella Craig
- Louis Dundas Centre for Children's Palliative Care, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
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15
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Domingo L, Carey JC, Eckhauser A, Wilkes J, Menon SC. Mortality and Resource Use Following Cardiac Interventions in Children with Trisomy 13 and Trisomy 18 and Congenital Heart Disease. Pediatr Cardiol 2019; 40:349-356. [PMID: 30291384 DOI: 10.1007/s00246-018-2001-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 09/28/2018] [Indexed: 11/24/2022]
Abstract
We sought to evaluate the mortality, risk factors for mortality, and resource utilization following cardiac interventions in trisomy 13 (T13) and 18 (T18) children. All T13 and T18 children who underwent a cardiac intervention from January 1999 to March 2015 were identified from the Pediatric Health Information System database. Data collected included demographics, type of congenital heart disease (CHD), cardiac interventions, comorbidities, length of stay (LOS), hospital charges, and deaths (within 30 days). Logistic regression analysis was used to determine factors associated with mortality. There were 49 (47% females) T13 and 140 (67% females) T18 subjects. The two cohorts were similar in distribution for race, geographic region, insurance type, and median household income. The most common CHD in both groups was a shunt lesion followed by conotruncal defects. Compared to T18, the T13 cohort had higher mortality (29% vs. 12%), tracheostomies (12% vs. 4%), gastrostomies (18% vs. 6%), and overall resource use (P < 0.05 for all). White race (OR 0.23, 95% CI 0.06-0.81) in T13 and older age (in weeks) at surgery in T18 (OR 0.75, 95% CI 0.64-0.86) were associated with lower mortality. A select group of T13 and T18 CHD patients can undergo successful cardiac interventions, albeit with a higher mortality and resource use. T13 patients have higher mortality and resource use compared to T18. In T13 and T18 patients, interventions for CHD may be an acceptable and ethical option following a careful individualized selection and counseling by a team of experts.
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Affiliation(s)
- Liezl Domingo
- Division of Pediatric Cardiology, University of Utah, Salt Lake City, UT, USA.
- Division of Pediatric Cardiology, Augusta University, 1120 15th Street BA, 8300, Augusta, GA, 30909, USA.
| | - John C Carey
- Division of Medical Genetics, University of Utah, Salt Lake City, UT, USA
| | - Aaron Eckhauser
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Jacob Wilkes
- Pediatric Specialties Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Shaji C Menon
- Division of Pediatric Cardiology, University of Utah, Salt Lake City, UT, USA
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16
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Kaulfus ME, Gardiner H, Hashmi SS, Mendez-Figueroa H, Miller VJ, Stevens B, Carter R. Attitudes of clinicians toward cardiac surgery and trisomy 18. J Genet Couns 2019; 28:654-663. [PMID: 30688390 DOI: 10.1002/jgc4.1089] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 12/05/2018] [Indexed: 11/06/2022]
Abstract
Trisomy 18 is an autosomal trisomy condition characterized by minor to major birth defects, severe disabilities, and high rates of pre- and postnatal mortality. Interventions for these infants have traditionally been withheld with focus instead on palliative support. The issues and attitudes surrounding corrective surgery of congenital heart defects, which is a birth defect that occurs in approximately 90% of infants with trisomy 18, is of our study's interest as recent literature has indicated that cardiac surgery is being performed and may lead to improved survival compared to palliative care. Thus, our study aimed to describe clinician attitudes toward cardiac surgery and trisomy 18. We surveyed 378 clinicians from multiple specialties, including genetic counselors, involved in the pre- and postnatal care of infants with trisomy 18. Descriptive statistics were performed to describe all clinicians' responses, and a secondary analysis with stratifications by clinician type was also performed. Forty-eight percent (n = 378) of clinicians felt it was appropriate to discuss the option of cardiac surgery. Ethical concerns and insufficient outcome data were the most agreed upon reasons for not offering cardiac surgery. Trisomy 18 not being uniformly lethal and expressed parental wishes were the most agreed upon justifications for offering surgery. Clinicians felt the discussion of the option of cardiac surgery is appropriate, however are hesitant due to ethical concerns and insufficient outcome data. Results from this study aim to promote discussion and collaboration among clinicians to improve consistency in patient care.
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Affiliation(s)
- Meagan E Kaulfus
- Clinical Cancer Genetics Program, MD Anderson Cancer Center, University of Texas Genetic Counseling Training Program, The University of Texas MD Anderson Cancer Center UT Health Graduate School of Biomedical Sciences, Houston, Texas
| | - Helena Gardiner
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at Houston, Houston, Texas
| | - S Shahrukh Hashmi
- Department of Pediatrics, McGovern Medical School at Houston, Houston, Texas
| | | | | | - Blair Stevens
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at Houston, Houston, Texas
| | - Rebecca Carter
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at Houston, Houston, Texas
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17
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Weaver MS, Starr LJ, Austin PN, Stevenson CL, Hammel JM. Eliciting Narratives to Inform Care for Infants With Trisomy 18. Pediatrics 2018; 142:peds.2018-0321. [PMID: 30190348 DOI: 10.1542/peds.2018-0321] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/01/2018] [Indexed: 11/24/2022] Open
Abstract
: media-1vid110.1542/5804913218001PEDS-VA_2018-0321Video Abstract.
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Affiliation(s)
- Meaghann S Weaver
- Divisions of Palliative Care and .,Departments of Oncology, Pediatrics and
| | - Lois J Starr
- Division of Clinical Genetics, Munroe-Meyer Institute for Genetics and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska; and
| | | | | | - James M Hammel
- Cardiothoracic Surgery, Children's Hospital and Medical Center, Omaha, Nebraska
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18
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Davisson NA, Clark JB, Chin TK, Tunks RD. Trisomy 18 and Congenital Heart Disease: Single-Center Review of Outcomes and Parental Perspectives. World J Pediatr Congenit Heart Surg 2018; 9:550-556. [DOI: 10.1177/2150135118782145] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: In patients with trisomy 18, congenital heart surgery is controversial due to anticipated poor patient outcome. Data are lacking regarding clinical outcomes and family opinions about care received. Methods: A retrospective chart review of patients with trisomy 18 and congenital heart disease from 2005 to 2017 was performed. Patients were grouped into those receiving cardiac intervention (surgery or cardiac catheterization) versus medical management. A telephone survey was used to assess completeness of family counseling provided prior to treatment selection and parental opinions on the care received. Results: Seventeen infants were assessed. In the medical management group (n = 7), there were five deaths at a median age of 1.5 months (range: 1.2-4.1 months) and two survivors aged 29 and 44 months at latest follow-up. In the intervention group (n = 10), cardiac surgery was performed in nine patients at a median age of 4.3 months (0.2-23.4 months) and weight of 3.2 kg (1.5-12.2 kg); catheter intervention was performed in one patient at one week of age. At latest follow-up, seven intervention patients are alive at a median age of 50 months (5-91 months). Survey respondents (n = 12) unanimously stated that their child’s quality of life was improved by their specific treatment strategy, that the experience of the parents was enhanced, and that they would choose the same treatment course again. Conclusions: Surgical repair may be associated with favorable early outcomes and may be judiciously offered in selected circumstances. In this limited experience, parental perceptions were positive regarding the quality of care and overall experience independent of the chosen treatment strategy or eventual outcome.
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Affiliation(s)
- Neena A. Davisson
- Department of Pediatrics, The Pennsylvania State University College of Medicine and Pennsylvania State Hershey Children’s Hospital, Hershey, PA, USA
| | - Joseph B. Clark
- Department of Surgery, The Pennsylvania State University College of Medicine and Pennsylvania State Hershey Children’s Hospital, Hershey, PA, USA
| | - Thomas K. Chin
- Department of Pediatrics, The Pennsylvania State University College of Medicine and Pennsylvania State Hershey Children’s Hospital, Hershey, PA, USA
| | - Robert D. Tunks
- Department of Pediatrics, The Pennsylvania State University College of Medicine and Pennsylvania State Hershey Children’s Hospital, Hershey, PA, USA
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19
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Abstract
Spontaneous regression of severe aortic coarctation with ductus dependency has not been reported. We experienced a case of trisomy 18 with spontaneous regression of severe aortic coarctation complicated by ventricular septal defect and patent ductus arteriosus. The aortic isthmus diameter was 1.2 mm at birth. After 5 months, it increased to 4.5 mm, and the shape of the isthmus was fully normalised.
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20
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Fruhman G, Miller C, Amon E, Raible D, Bradshaw R, Martin K. Obstetricians' views on the ethics of cardiac surgery for newborns with common aneuploidies. Prenat Diagn 2018; 38:303-309. [DOI: 10.1002/pd.5225] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 01/21/2018] [Accepted: 01/25/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Gary Fruhman
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Women's Health; Saint Louis University School of Medicine; Saint Louis MO USA
- Northwell Health, Department of Obstetrics and Gynecology; Staten Island University Hospital; Staten Island NY USA
| | - Collin Miller
- Division of Research, Department of Obstetrics, Gynecology, and Women's Health; Saint Louis University School of Medicine; Saint Louis MO USA
| | - Erol Amon
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Women's Health; Saint Louis University School of Medicine; Saint Louis MO USA
| | - Darbey Raible
- Department of Pediatrics; Saint Louis University School of Medicine; Saint Louis MO USA
| | - Rachael Bradshaw
- Department of Pediatrics; Saint Louis University School of Medicine; Saint Louis MO USA
| | - Kimberly Martin
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Women's Health; Saint Louis University School of Medicine; Saint Louis MO USA
- Natera Inc.; San Carlos CA USA
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21
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Peterson R, Calamur N, Fiore A, Huddleston C, Spence K. Factors Influencing Outcomes After Cardiac Intervention in Infants with Trisomy 13 and 18. Pediatr Cardiol 2018; 39:140-147. [PMID: 28948390 DOI: 10.1007/s00246-017-1738-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 09/13/2017] [Indexed: 10/18/2022]
Abstract
Cardiac intervention remains controversial in patients with trisomy 13 and 18 and little is known about factors that may affect outcomes. The goal of this study was to evaluate preoperative factors and surgical approach with respect to outcomes in these patients. Patients with congenital heart disease and trisomy 13 or 18 presenting to our institution from 2004 through 2015 were retrospectively reviewed. Patients were grouped into complete intervention, palliated intervention, and non-intervention. Pre-intervention variables, timing and type of intervention, post-intervention outcomes, and survival were recorded and comparisons were made between the groups. Of 34 patients, 18 cardiac interventions were performed. Complete repair was performed in 11(61%) and palliation in 7(39%). Median age for complete repair was 9.2 vs. 1.7 months in palliated patients (p < 0.001) and palliated patients were smaller (median 2.5 vs. 5.2 kg, p < 0.001). All patients who underwent complete repair survived to discharge compared to only 57% of patients that were palliated (p = 0.04). Palliated patients had longer intubation and time to discharge (p < 0.05). Survival at last follow-up was greater in the complete repair group compared with palliated patients and non-intervention patients (72, 14, and 18%, p = 0.009) with a longer median length of survival in the complete repair group (p = 0.002). In our group of trisomy 13 and 18 patients, those able to undergo complete repair had improved outcomes. Patients undergoing complete repair were older and bigger; this suggests that delaying intervention and optimizing the likelihood of complete repair may be beneficial.
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Affiliation(s)
- Renuka Peterson
- Department of Pediatrics, Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Medical Center, 1465 S. Grand Boulevard, Saint Louis, MO, 63104, USA.
| | - Nandini Calamur
- Department of Pediatrics, Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Medical Center, 1465 S. Grand Boulevard, Saint Louis, MO, 63104, USA
| | - Andrew Fiore
- Department of Surgery, Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Medical Center, Saint Louis, MO, USA
| | - Charles Huddleston
- Department of Surgery, Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Medical Center, Saint Louis, MO, USA
| | - Kimberly Spence
- Department of Pediatrics, Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Medical Center, 1465 S. Grand Boulevard, Saint Louis, MO, 63104, USA
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22
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Long-Term Outcomes of Children With Trisomy 13 and 18 After Congenital Heart Disease Interventions. Ann Thorac Surg 2017; 103:1941-1949. [PMID: 28456396 DOI: 10.1016/j.athoracsur.2017.02.068] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 02/15/2017] [Accepted: 02/21/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND The purpose of this study is to report short- and long-term outcomes after congenital heart defect (CHD) interventions in patients with trisomy 13 or 18. METHODS A retrospective review of the Pediatric Cardiac Care Consortium (PCCC) identified children with trisomy 13 or 18 with interventions for CHD between 1982 and 2008. Long-term survival and cause of death were obtained through linkage with the National Death Index. RESULTS A total of 50 patients with trisomy 13 and 121 patients with trisomy 18 were enrolled in PCCC between 1982 and 2008; among them 29 patients with trisomy 13 and 69 patients with trisomy 18 underwent intervention for CHD. In-hospital mortality rates for patients with trisomy 13 or trisomy 18 were 27.6% and 13%, respectively. Causes of in-hospital death were primarily cardiac (64.7%) or multiple organ system failure (17.6%). National Death Index linkage confirmed 23 deaths after discharge. Median survival (conditioned to hospital discharge) was 14.8 years (95% confidence interval [CI]: 12.3 to 25.6 years) for patients with trisomy 13 and 16.2 years (95% CI: 12 to 20.4 years) for patients with trisomy 18. Causes of late death included cardiac (43.5%), respiratory (26.1%), and pulmonary hypertension (13%). CONCLUSIONS In-hospital mortality rate for all surgical risk categories was higher in patients with trisomy 13 or 18 than that reported for the general population. However, patients with trisomy 13 or 18, who were selected as acceptable candidates for cardiac intervention and who survived CHD intervention, demonstrated longer survival than previously reported. These findings can be used to counsel families and make program-level decisions on offering intervention to carefully selected patients.
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23
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Hasegawa SL, Fry JT. Moving toward a shared process: The impact of parent experiences on perinatal palliative care. Semin Perinatol 2017; 41:95-100. [PMID: 28238454 DOI: 10.1053/j.semperi.2016.11.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Perinatal palliative care programs seek to support parents expecting a baby diagnosed with a serious medical condition. Clinicians have increasingly recognized the importance of parental perspectives on the medical care mothers and their fetuses and live-born children receive, especially regarding factors influencing individual choices and knowledge of the medical community. We describe, using literature on trisomy 13 and trisomy 18, how information shared between parents and providers can improve perinatal counseling and family support.
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Affiliation(s)
- Susan L Hasegawa
- Division of Neonatology, Ann & Robert H. Lurie Children's Hospital of Chicago, Box 45, 225 E. Chicago Ave, Chicago, IL 60611
| | - Jessica T Fry
- Division of Neonatology, Ann & Robert H. Lurie Children's Hospital of Chicago, Box 45, 225 E. Chicago Ave, Chicago, IL 60611.
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24
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Kuo KW, Barbaro RP, Gadepalli SK, Davis MM, Bartlett RH, Odetola FO. Should Extracorporeal Membrane Oxygenation Be Offered? An International Survey. J Pediatr 2017; 182:107-113. [PMID: 28041665 DOI: 10.1016/j.jpeds.2016.12.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 10/26/2016] [Accepted: 12/07/2016] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To assess the current attitudes of extracorporeal membrane oxygenation (ECMO) program directors regarding eligibility for ECMO among children with cardiopulmonary failure. STUDY DESIGN Electronic cross-sectional survey of ECMO program directors at ECMO centers worldwide within the Extracorporeal Life Support Organization directory (October 2015-December 2015). RESULTS Of 733 eligible respondents, 226 (31%) completed the survey, 65% of whom routinely cared for pediatric patients. There was wide variability in whether respondents would offer ECMO to any of the 5 scenario patients, ranging from 31% who would offer ECMO to a child with trisomy 18 to 76% who would offer ECMO to a child with prolonged cardiac arrest and indeterminate neurologic status. Even physicians practicing the same specialty sometimes held widely divergent opinions, with 50% of pediatric intensivists stating they would offer ECMO to a child with severe developmental delay and 50% stating they would not. Factors such as quality of life and neurologic status influenced decision making and were used to support decisions for and against offering ECMO. CONCLUSIONS ECMO program directors vary widely in whether they would offer ECMO to various children with cardiopulmonary failure. This heterogeneity in physician decision making underscores the need for more evidence that could eventually inform interinstitutional guidelines regarding patient selection for ECMO.
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Affiliation(s)
- Kevin W Kuo
- Division of Pediatric Critical Care, Department of Pediatrics, University of Michigan, Ann Arbor, MI.
| | - Ryan P Barbaro
- Division of Pediatric Critical Care, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | | | - Matthew M Davis
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern Feinberg School of Medicine, Chicago, IL
| | | | - Folafoluwa O Odetola
- Division of Pediatric Critical Care, Department of Pediatrics, University of Michigan, Ann Arbor, MI
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25
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Abstract
BACKGROUND Surgical repair for cardiac lesions has rarely been offered to patients with trisomy 18 because of their very short lifespans. We investigated the effectiveness of cardiac surgery in patients with trisomy 18. Patients and methods We performed a retrospective analysis of 20 consecutive patients with trisomy 18 and congenital cardiac anomalies who were evaluated between August, 2003 and July, 2013. All patients developed respiratory or cardiac failure due to excessive pulmonary blood flow. Patients were divided into two subgroups: one treated surgically (surgical group, n=10) and one treated without surgery (conservative group, n=10), primarily to compare the duration of survival between the groups. RESULTS All the patients in the surgical group underwent cardiac surgery with pulmonary artery banding, including patent ductus arteriosus ligation in nine patients and coarctation repair in one. The duration of survival was significantly longer in the surgical group than in the conservative group (495.4±512.6 versus 93.1±76.2 days, respectively; p=0.03). A Cox proportional hazard model found cardiac surgery to be a significant predictor of survival time (risk ratio of 0.12, 95% confidence interval 0.016-0.63; p=0.01). CONCLUSIONS Cardiac surgery was effective in prolonging survival by managing high pulmonary blood flow; however, the indication for surgery should be carefully considered on a case-by-case basis, because the risk of sudden death remains even after surgery. Patients' families should be provided with sufficient information to make decisions that will optimise the quality of life for both patients and their families.
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26
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Josephsen JB, Armbrecht ES, Braddock SR, Cibulskis CC. Procedures in the 1st year of life for children with trisomy 13 and trisomy 18, a 25-year, single-center review. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2016; 172:264-71. [DOI: 10.1002/ajmg.c.31525] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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27
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Matricardi S, Spalice A, Salpietro V, Di Rosa G, Balistreri MC, Grosso S, Parisi P, Elia M, Striano P, Accorsi P, Cusmai R, Specchio N, Coppola G, Savasta S, Carotenuto M, Tozzi E, Ferrara P, Ruggieri M, Verrotti A. Epilepsy in the setting of full trisomy 18: A multicenter study on 18 affected children with and without structural brain abnormalities. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2016; 172:288-95. [DOI: 10.1002/ajmg.c.31513] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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28
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McCaffrey MJ. Trisomy 13 and 18: Selecting the road previously not taken. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2016; 172:251-6. [PMID: 27519759 DOI: 10.1002/ajmg.c.31512] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The care of patients with trisomy 13 and 18 is a source of significant controversy. While these conditions are life limiting, indisputable data refutes the notion that these conditions are lethal or incompatible with life. Despite such evidence, arguments of beneficence, quality of life and limited resources are invoked to make the case to limit care to trisomy children. Lessons learned in our ignominious history with Down syndrome should guide us as we explore care for patients with trisomy 13 and 18. As clinicians we should strive with equipoise to carefully examine available data, the current status of practices related to care from palliation to intensive interventions, rise above our personal prejudices and listen to the voices of families imploring us to consider their opinions regarding the value of the life of a child with trisomy 13 or 18. We should recall and learn from our Down syndrome odyssey and select the road previously not taken as we chart a course to the best possible care for our trisomy 13 and 18 sisters and brothers. © 2016 Wiley Periodicals, Inc.
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29
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Graham EM. Infants with Trisomy 18 and Complex Congenital Heart Defects Should Not Undergo Open Heart Surgery. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2016; 44:286-291. [PMID: 27338604 DOI: 10.1177/1073110516654122] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Aggressive medical and surgical interventions have not been clearly demonstrated to improve survival in neonates with trisomy 18; there are no data that demonstrates improved quality of life for these children after these interventions; and these interventions are clearly associated with significant morbidity, resource allocation, and cost.
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Affiliation(s)
- Eric M Graham
- Eric M. Graham, M.D., is a physician in the Division of Pediatric Cardiology at the Medical University of South Carolina
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30
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Abstract
The objective is to examine whether cardiac surgery should be considered for children with trisomy 13 or 18 (T13 or 18).T13 or 18 were previously referred to as "lethal" conditions due to high mortality rates and severe disability among survivors. In the last decade, investigations have revealed these conditions are heterogeneous, with increasing numbers of studies describing interventions for these children. A number of factors makes the interpretation of reported outcomes after cardiac surgery challenging: (1) dissimilarities in practice lead to a wide variation in reported outcomes after cardiac surgery; (2) cardiac surgery is generally offered to older, healthier children; (3) cardiac surgeries of widely varying risks are often lumped together in individual studies, and (4) cases where cardiac surgery has been withheld are generally not included in publications. It is unclear whether withholding cardiac surgery for some children with a ventricular septal defect will lead to death, or the development of pulmonary hypertension, or if death will occur from other causes. In this article, we describe two children with different clinical situations and examine whether cardiac surgery would benefit them and how to communicate with their families. Cardiac surgery may be beneficial to some children with trisomy 13 or 18, but may harm others. Every child should be approached in an individual fashion and the goals of each family should be addressed. Children who are more likely to benefit from surgery may be older, healthier children without respiratory support. Rigorous and transparent research is needed to identify factors that affect survival in trisomy 13 or 18.
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Affiliation(s)
- Annie Janvier
- Department of Pediatrics, University of Montreal, Montreal, Canada; Unité d'éthique clinique, Hôpital Sainte-Justine, Quebec, Canada; Research Center, Hôpital Sainte-Justine, Quebec, Canada.
| | - Barbara Farlow
- The DeVeber Institute for Bioethics and Social Research, Ontario, Canada; Patients for Patient Safety, Ontario, Canada
| | - Keith Barrington
- Department of Pediatrics, University of Montreal, Montreal, Canada; Research Center, Hôpital Sainte-Justine, Quebec, Canada
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Kosho T, Carey JC. Does medical intervention affect outcome in infants with trisomy 18 or trisomy 13? Am J Med Genet A 2016; 170A:847-9. [DOI: 10.1002/ajmg.a.37610] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 02/22/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Tomoki Kosho
- Department of Medical Genetics; Shinshu University School of Medicine; Matsumoto Japan
| | - John C. Carey
- Department of Pediatrics; University of Utah Health Sciences Center; Salt Lake City Utah
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Imataka G, Suzumura H, Arisaka O. Clinical features and survival in individuals with trisomy 18: A retrospective one-center study of 44 patients who received intensive care treatments. Mol Med Rep 2016; 13:2457-66. [PMID: 26820816 PMCID: PMC4768975 DOI: 10.3892/mmr.2016.4806] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 01/21/2016] [Indexed: 11/05/2022] Open
Abstract
Trisomy 18 syndrome is a common autosomal aneuploidy chromosomal abnormality caused by the presence of extra chromosome 18 that leads to malformations of various parts of the body. In this study, we retrospectively investigated the effect of the medical progression and prognosis of 44 cases of trisomy 18, admitted to our neonatal intensive care unit between 1992 and 2013. The patients were divided into group A (n=20, 1992‑2002) and group B (n=24, 2003‑2012). Following delivery, karyotype, gender, gestational weeks, birth place, cesarean section, Apgar score and birth weight were analyzed using the Fisher's exact test, unpaired t‑test and Mann‑Whitney U test. Based on the statistical results, a comparison was made of the two groups and no significant differences were observed. Clinical data of major complications, mechanical ventilation, discharge from hospital and survival days were reviewed for the cases of trisomy 18. Of the 44 patients, 42 had cardiac anomaly, 16 had esophageal atresia, and 3 patients had brain anomaly. Ventilation treatment was performed in 29 cases (65.9%) and an increased percentage was identified in group B patients. The percentage survival was estimated using Kaplan‑Meier curves and the two groups were analyzed using the generalized Wilcoxon test. Improvement in life prognosis was observed in group B as compared to group A. The log‑rank test was used to assess survey periods of 180 days, 1 year, and the entire observation period. Although significant differences were observed for the prognosis of trisomy 18 at 180 days after birth, after 1 year and the entire survey period after birth, the significant differences were not confirmed. In conclusion, results of the present study provide information concerning genetic counseling for parents/guardians and life prognosis, prior to applying intensive management to newborns with trisomy 18.
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Affiliation(s)
- George Imataka
- Department of Pediatrics, Dokkyo Medical University School of Medicine, Shimotsuga, Tocihgi 321‑0293, Japan
| | - Hiroshi Suzumura
- Department of Pediatrics, Dokkyo Medical University School of Medicine, Shimotsuga, Tocihgi 321‑0293, Japan
| | - Osamu Arisaka
- Department of Pediatrics, Dokkyo Medical University School of Medicine, Shimotsuga, Tocihgi 321‑0293, Japan
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Subramaniam A, Jacobs AP, Tang Y, Neely C, Philips JB, Biggio JR, Robin NH, Edwards RK. Trisomy 18: A single-center evaluation of management trends and experience with aggressive obstetric or neonatal intervention. Am J Med Genet A 2016; 170A:838-46. [DOI: 10.1002/ajmg.a.37529] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 12/09/2015] [Indexed: 11/06/2022]
Affiliation(s)
- Akila Subramaniam
- Division of Maternal-Fetal Medicine; Department of Obstetrics and Gynecology; University of Alabama at Birmingham; Birmingham Alabama
- Department of Genetics; University of Alabama at Birmingham; Birmingham Alabama
| | - Adam P. Jacobs
- School of Medicine; University of Alabama at Birmingham; Birmingham Alabama
| | - Ying Tang
- Division of Maternal-Fetal Medicine; Department of Obstetrics and Gynecology; University of Alabama at Birmingham; Birmingham Alabama
| | - Cherry Neely
- Division of Maternal-Fetal Medicine; Department of Obstetrics and Gynecology; University of Alabama at Birmingham; Birmingham Alabama
| | - Joseph B. Philips
- Division of Neonatology; Department of Pediatrics; University of Alabama at Birmingham; Birmingham Alabama
| | - Joseph R. Biggio
- Division of Maternal-Fetal Medicine; Department of Obstetrics and Gynecology; University of Alabama at Birmingham; Birmingham Alabama
| | - Nathaniel H. Robin
- Department of Genetics; University of Alabama at Birmingham; Birmingham Alabama
- Division of Neonatology; Department of Pediatrics; University of Alabama at Birmingham; Birmingham Alabama
| | - Rodney K. Edwards
- Division of Maternal-Fetal Medicine; Department of Obstetrics and Gynecology; University of Alabama at Birmingham; Birmingham Alabama
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Nagase H, Ishikawa H, Toyoshima K, Itani Y, Furuya N, Kurosawa K, Hirahara F, Yamanaka M. Fetal outcome of trisomy 18 diagnosed after 22 weeks of gestation: Experience of 123 cases at a single perinatal center. Congenit Anom (Kyoto) 2016; 56:35-40. [PMID: 26104883 DOI: 10.1111/cga.12118] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 06/16/2015] [Indexed: 11/26/2022]
Abstract
To investigate the pregnancy outcome of the fetuses with trisomy 18, we studied 123 cases of trisomy 18 who were born at our hospital from 1993 to 2009. Among them, 95.9% were diagnosed with trisomy 18 prenatally. Prenatal ultrasound findings showed fetal growth restriction in 77.2%, polyhydramnios in 63.4% and congenital heart defects in 95.1%. For 18 cases, cesarean section (C-section) was chosen, and for 75 cases, transvaginal delivery was chosen. Premature delivery occurred in 35.5%. Stillbirths occurred in 50 cases (40.7%). Fetal demise before onset of labor occurred in 30 cases and fetal demise during labor occurred in 20 cases which was 26.7% of vaginal deliveries. Among the 73 live-born infants, the survival rate for 24 h, 1 week, 1 month and 1 year were 63%, 43%, 33% and 3%. The median survival time was 3.5 days. There was no significant difference between the survival time of C-section and that of vaginal delivery. However, for the births involving breech presentation, the survival time of C-section was significantly longer than that of vaginal delivery. When the fetus is diagnosed with trisomy 18, the parents have to make many choices. These findings constitute critical information in prenatal counseling to the couples whose fetuses have been found to have trisomy 18, especially when they choose palliative approaches in the perinatal management.
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Affiliation(s)
- Hiromi Nagase
- Division of Obstetrics and Gynecology, Kanagawa Children's Medical Center, Yokohama, Kanagawa, Japan.,Department of Obstetrics and Gynecology, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Hiroshi Ishikawa
- Division of Obstetrics and Gynecology, Kanagawa Children's Medical Center, Yokohama, Kanagawa, Japan
| | - Katsuaki Toyoshima
- Division of Neonatology, Kanagawa Children's Medical Center, Yokohama, Kanagawa, Japan
| | - Yasufumi Itani
- Division of Neonatology, Kanagawa Children's Medical Center, Yokohama, Kanagawa, Japan
| | - Noritaka Furuya
- Division of Pediatrics, Saitama Citizens Medical Center, Saitama, Saitama, Japan
| | - Kenji Kurosawa
- Division of Medical Genetics, Kanagawa Children's Medical Center, Yokohama, Kanagawa, Japan
| | - Fumiki Hirahara
- Department of Obstetrics and Gynecology, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Michiko Yamanaka
- Department of Integrated Women's Health, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan
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Meyer RE, Liu G, Gilboa SM, Ethen MK, Aylsworth AS, Powell CM, Flood TJ, Mai CT, Wang Y, Canfield MA. Survival of children with trisomy 13 and trisomy 18: A multi-state population-based study. Am J Med Genet A 2015; 170A:825-37. [PMID: 26663415 DOI: 10.1002/ajmg.a.37495] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 11/20/2015] [Indexed: 11/12/2022]
Abstract
Trisomy 13 (T13) and trisomy 18 (T18) are among the most prevalent autosomal trisomies. Both are associated with a very high risk of mortality. Numerous instances, however, of long-term survival of children with T13 or T18 have prompted some clinicians to pursue aggressive treatment instead of the traditional approach of palliative care. The purpose of this study is to assess current mortality data for these conditions. This multi-state, population-based study examined data obtained from birth defect surveillance programs in nine states on live-born infants delivered during 1999-2007 with T13 or T18. Information on children's vital status and selected maternal and infant risk factors were obtained using matched birth and death certificates and other data sources. The Kaplan-Meier method and Cox proportional hazards models were used to estimate age-specific survival probabilities and predictors of survival up to age five. There were 693 children with T13 and 1,113 children with T18 identified from the participating states. Among children with T13, 5-year survival was 9.7%; among children with T18, it was 12.3%. For both trisomies, gestational age was the strongest predictor of mortality. Females and children of non-Hispanic black mothers had the lowest mortality. Omphalocele and congenital heart defects were associated with an increased risk of death for children with T18 but not T13. This study found survival among children with T13 and T18 to be somewhat higher than those previously reported in the literature, consistent with recent studies reporting improved survival following more aggressive medical intervention for these children. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Robert E Meyer
- N.C. Division of Public Health, Birth Defects Monitoring Program, State Center for Health Statistics, Raleigh, North Carolina
| | - Gang Liu
- Department of Epidemiology and Biostatistics, University of Albany, State University of New York, Albany, New York
| | - Suzanne M Gilboa
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mary K Ethen
- Texas Department of State Health Services, Birth Defects Epidemiology and Surveillance Branch, Austin, Texas
| | - Arthur S Aylsworth
- Departments of Pediatrics and Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Cynthia M Powell
- Departments of Pediatrics and Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Timothy J Flood
- Arizona Department of Health Services, Birth Defects Monitoring Program, Phoenix, Arizona
| | - Cara T Mai
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ying Wang
- New York State Department of Health, Office of Primary Care and Health System Management, Albany, New York
| | - Mark A Canfield
- Texas Department of State Health Services, Birth Defects Epidemiology and Surveillance Branch, Austin, Texas
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Costello JP, Weiderhold A, Louis C, Shaughnessy C, Peer SM, Zurakowski D, Jonas RA, Nath DS. A contemporary, single-institutional experience of surgical versus expectant management of congenital heart disease in trisomy 13 and 18 patients. Pediatr Cardiol 2015; 36:987-92. [PMID: 25612784 DOI: 10.1007/s00246-015-1109-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 01/13/2015] [Indexed: 11/25/2022]
Abstract
The objective of this study was to examine a large institutional experience of patients with trisomy 13 and trisomy 18 in the setting of comorbid congenital heart disease and present the outcomes of surgical versus expectant management. It is a retrospective single-institution cohort study. Institutional review board approved this study. Thirteen consecutive trisomy 18 patients and three consecutive trisomy 13 patients (sixteen patients in total) with comorbid congenital heart disease who were evaluated by our institution's Division of Cardiovascular Surgery between January 2008 and December 2013 were included in the study. The primary outcome measures evaluated were operative mortality (for patients who received surgical management), overall mortality (for patients who received expectant management), and total length of survival during follow-up. Of the thirteen trisomy 18 patients, seven underwent surgical management and six received expectant management. With surgical management, operative mortality was 29 %, and 80 % of patients were alive after a median follow-up of 116 days. With expectant management, 50 % of patients died before hospital discharge. Of the three patients with trisomy 13, one patient underwent surgical management and two received expectant management. The patient who received surgical management with complete repair was alive at last follow-up over 2 years after surgery; both patients managed expectantly died before hospital discharge. Trisomy 13 and trisomy 18 patients with comorbid congenital heart disease can undergo successful cardiac surgical intervention. In this population, we advocate that nearly all patients with cardiovascular indications for operative congenital heart disease intervention should be offered complete surgical repair over palliative approaches for moderately complex congenital cardiac anomalies.
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Affiliation(s)
- John P Costello
- Division of Cardiovascular Surgery, Children's National Health System, 111 Michigan Avenue, NW, Washington, DC, 20010, USA
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38
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Abstract
PURPOSE OF REVIEW To review the evolving management of infants/children with trisomy 18, the prognosis with and without medical intervention, the factors that have contributed to the evolving management strategies, and an approach to the formulation of healthcare management plans for newborns with trisomy 18. RECENT FINDINGS There has been a trend from nonintervention for infants/children with trisomy 18 toward management to prolong life. It has become clear that the prognosis for infants/children with trisomy 18 is not as 'hopeless' as was once asserted. However, case series of patients with trisomy 18 managed with a goal of prolonging life are not adequate to evaluate the efficacy of these interventions. They are also not adequate to support the contention that they have no efficacy. In fact, anecdotal evidence and medical plausibility suggest that treatment can prolong life in some cases. This trend has been supported by a change in emphasis from a largely physician-directed model of medical decision-making to a collaborative model, which respects parents' rights to make healthcare decisions for their children and recognizes that judgments about outcomes are often subjective, and social networks, which support and advocate for children with trisomy 18 and their families. An approach to collaborative medical decision-making that is goal-directed is recommended. SUMMARY Healthcare management approaches or policies that reject out of hand the goal of prolonging the life of any infant/child with trisomy 18 are not defensible. Management plans should be goal-directed, based on the physician-parent evaluation of the benefits and burdens of care options for the individual child.
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Boghossian NS, Hansen NI, Bell EF, Stoll BJ, Murray JC, Carey JC, Adams-Chapman I, Shankaran S, Walsh MC, Laptook AR, Faix RG, Newman NS, Hale EC, Das A, Wilson LD, Hensman AM, Grisby C, Collins MV, Vasil DM, Finkle J, Maffett D, Ball MB, Lacy CB, Bara R, Higgins RD. Mortality and morbidity of VLBW infants with trisomy 13 or trisomy 18. Pediatrics 2014; 133:226-35. [PMID: 24446439 PMCID: PMC3904274 DOI: 10.1542/peds.2013-1702] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE Little is known about how very low birth weight (VLBW) affects survival and morbidities among infants with trisomy 13 (T13) or trisomy 18 (T18). We examined the care plans for VLBW infants with T13 or T18 and compared their risks of mortality and neonatal morbidities with VLBW infants with trisomy 21 and VLBW infants without birth defects. METHODS Infants with birth weight 401 to 1500 g born or cared for at a participating center of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network during the period 1994-2009 were studied. Poisson regression models were used to examine risk of death and neonatal morbidities among infants with T13 or T18. RESULTS Of 52,262 VLBW infants, 38 (0.07%) had T13 and 128 (0.24%) had T18. Intensity of care in the delivery room varied depending on whether the trisomy was diagnosed before or after birth. The plan for subsequent care for the majority of the infants was to withdraw care or to provide comfort care. Eleven percent of infants with T13 and 9% of infants with T18 survived to hospital discharge. Survivors with T13 or T18 had significantly increased risk of patent ductus arteriosus and respiratory distress syndrome compared with infants without birth defects. No infant with T13 or T18 developed necrotizing enterocolitis. CONCLUSIONS In this cohort of liveborn VLBW infants with T13 or T18, the timing of trisomy diagnosis affected the plan for care, survival was poor, and death usually occurred early.
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Affiliation(s)
- Nansi S. Boghossian
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Nellie I. Hansen
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Barbara J. Stoll
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | - John C. Carey
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Ira Adams-Chapman
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Michele C. Walsh
- Department of Pediatrics, Case Western Reserve University and Rainbow Babies & Children’s Hospital, Cleveland, Ohio
| | - Abbot R. Laptook
- Department of Pediatrics, Brown University and Women & Infants Hospital of Rhode Island, Providence, Rhode Island
| | - Roger G. Faix
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Nancy S. Newman
- Department of Pediatrics, Case Western Reserve University and Rainbow Babies & Children’s Hospital, Cleveland, Ohio
| | - Ellen C. Hale
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, Maryland
| | - Leslie D. Wilson
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Angelita M. Hensman
- Department of Pediatrics, Brown University and Women & Infants Hospital of Rhode Island, Providence, Rhode Island
| | - Cathy Grisby
- Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Monica V. Collins
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Diana M. Vasil
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joanne Finkle
- Department of Pediatrics, Duke University, Durham, North Carolina
| | - Deanna Maffett
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - M. Bethany Ball
- Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California; and
| | - Conra B. Lacy
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Rebecca Bara
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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Nam SY, Ahn SY, Chun JY, Yoon SA, Park GY, Choi SY, Sung SI, Yoo HS, Chang YS, Park WS. Survival of Patients with Trisomy 18 Based on the Treatment Policy at a Single Center in Korea. NEONATAL MEDICINE 2014. [DOI: 10.5385/nm.2014.21.4.251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Soon Young Nam
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - So Yoon Ahn
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji-young Chun
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Shin Ae Yoon
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ga Young Park
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo Young Choi
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Se In Sung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye Soo Yoo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yun Sil Chang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Soon Park
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Nishi E, Takamizawa S, Iio K, Yamada Y, Yoshizawa K, Hatata T, Hiroma T, Mizuno S, Kawame H, Fukushima Y, Nakamura T, Kosho T. Surgical intervention for esophageal atresia in patients with trisomy 18. Am J Med Genet A 2013; 164A:324-30. [PMID: 24311518 DOI: 10.1002/ajmg.a.36294] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 09/16/2013] [Indexed: 11/10/2022]
Abstract
Trisomy 18 is a common chromosomal aberration syndrome involving growth impairment, various malformations, poor prognosis, and severe developmental delay in survivors. Although esophageal atresia (EA) with tracheoesophageal fistula (TEF) is a potentially fatal complication that can only be rescued through surgical correction, no reports have addressed the efficacy of surgical intervention for EA in patients with trisomy 18. We reviewed detailed clinical information of 24 patients with trisomy 18 and EA who were admitted to two neonatal intensive care units in Japan and underwent intensive treatment including surgical interventions from 1982 to 2009. Nine patients underwent only palliative surgery, including six who underwent only gastrostomy or both gastrostomy and jejunostomy (Group 1) and three who underwent gastrostomy and TEF division (Group 2). The other 15 patients underwent radical surgery, including 10 who underwent single-stage esophago-esophagostomy with TEF division (Group 3) and five who underwent two-stage operation (gastrostomy followed by esophago-esophagostomy with TEF division) (Group 4). No intraoperative death or anesthetic complications were noted. Enteral feeding was accomplished in 17 patients, three of whom were fed orally. Three patients could be discharged home. The 1-year survival rate was 17%: 27% in those receiving radical surgery (Groups 3 and 4); 0% in those receiving palliative surgery (Groups 1 and 2). Most causes of death were related to cardiac complications. EA is not an absolute poor prognostic factor in patients with trisomy 18 undergoing radical surgery for EA and intensive cardiac management.
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Affiliation(s)
- Eriko Nishi
- Division of Medical Genetics, Nagano Children's Hospital, Azumino, Japan; Department of Medical Genetics, Shinshu University Graduate School of Medicine, Matsumoto, Japan
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Guon J, Wilfond BS, Farlow B, Brazg T, Janvier A. Our children are not a diagnosis: the experience of parents who continue their pregnancy after a prenatal diagnosis of trisomy 13 or 18. Am J Med Genet A 2013; 164A:308-18. [PMID: 24311520 DOI: 10.1002/ajmg.a.36298] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 09/10/2013] [Indexed: 11/09/2022]
Abstract
Trisomy 13 and trisomy 18 (T13-18) are associated with high rates of perinatal death and with severe disability among survivors. Prenatal diagnosis (PND) may lead many women to terminate their pregnancy but some women choose to continue their pregnancy. We sent 503 invitations to answer a questionnaire to parents who belong to T13 and 18 internet support groups. Using mixed methods, we asked parents about their prenatal experience, their hopes, the life of their affected child, and their family experience. 332 parents answered questions about 272 children; 128 experienced PND. These parents, despite feeling pressure to terminate (61%) and being told that their baby would likely die before birth (94%), chose to continue the pregnancy. Their reasons included: moral beliefs (68%), child-centered reasons (64%), religious beliefs (48%), parent-centered reasons (28%), and practical reasons (6%). At the time of the diagnosis, most of these parents (80%) hoped to meet their child alive. By the time of birth, 25% chose a plan of full interventions. A choice of interventions at birth was associated with fewer major anomalies (P < 0.05). Parents describe "Special" healthcare providers as those who gave balanced and personalized information, respected their choice, and provided support. Parents make decisions to continue a pregnancy and choose a plan of care for their child according to their beliefs and their child's specific medical condition, respectively. Insights from parents' perspective can better enable healthcare providers to counsel and support families.
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Janvier A, Watkins A. Medical interventions for children with trisomy 13 and trisomy 18: what is the value of a short disabled life? Acta Paediatr 2013; 102:1112-7. [PMID: 24112219 DOI: 10.1111/apa.12424] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 09/18/2013] [Indexed: 11/28/2022]
Abstract
UNLABELLED Children with trisomy 13 and trisomy 18 (T13 or T18) have low survival rates, and survivors have significant disabilities. Life saving interventions (LSIs) are generally not recommended by many healthcare providers (HCPs). After a diagnosis of T13 or T18, many parents chose termination of pregnancy or comfort care at birth, but others consider treatment to prolong the lives of their children. While LSIs may be effective at prolonging the life of some children, the quality of life of survivors and the possible burden on the family may be considered negatively by HCP, which may lead to conflicts with families. Resource allocation considerations are often invoked to withhold LSI for T13 or T18 even though they are seldom mentioned for older patients with comparable outcomes. CONCLUSION We should strive to improve communication with parents by 1. Investigating these conditions further to be able to better inform parents and 2. Providing balanced information for families and personalised care for each child.
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Affiliation(s)
- Annie Janvier
- Department of Pediatrics and Clinical Ethics; Neonatology and Clinical Ethics; Sainte-Justine Hospital; University of Montreal; Montreal QC Canada
| | - Andrew Watkins
- Department of Paediatrics; Mercy Hospital for Women; Heidelberg Melbourne Vic. Australia
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Kahramaner Z, Erdemir A, Cosar H, Turkoglu E, Sutcuoglu S, Turelik O, Cumurcu S, Bayol U, Ozer E. An unusual case of trisomy 18 associated with paucity of bile ducts. Fetal Pediatr Pathol 2013; 32:337-40. [PMID: 23421547 DOI: 10.3109/15513815.2013.768736] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A case of neonatal cholestasis associated with Trisomy 18 (Edward's syndrome) is presented. A 3-day-old boy was referred to our clinic due to respiratory distress, elevated serum direct bilirubin levels, a systolic heart murmur, growth restriction and micrognathia. Liver biopsy and chromosomal analysis revealed paucity of intrahepatic bile ducts and Trisomy 18. Extrahepatic biliary atresia was reported in only a few patients with Trisomy 18. To our knowledge, we described for the first time a patient with Trisomy 18 and neonatal cholestasis associated with paucity of interlobular bile ducts.
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Affiliation(s)
- Zelal Kahramaner
- Department of Pediatrics, Division of Neonatology, Ministry of Health, Izmir Tepecik Research and Teaching Hospital, Turkey
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Boss RD, Holmes KW, Althaus J, Rushton CH, McNee H, McNee T. Trisomy 18 and complex congenital heart disease: seeking the threshold benefit. Pediatrics 2013; 132:161-5. [PMID: 23733790 DOI: 10.1542/peds.2012-3643] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
A prenatal diagnosis of ductal-dependent, complex congenital heart disease was made in a fetus with trisomy 18. The parents requested that the genetic diagnosis be excluded from all medical and surgical decision-making and that all life-prolonging therapies be made available to their infant. There was conflict among the medical team about what threshold of neonatal benefit could outweigh maternal and neonatal treatment burdens. A prenatal ethics consultation was requested.
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Affiliation(s)
- Renee D Boss
- Department of Pediatrics, Johns Hopkins University School of Medicine, Johns Hopkins University School of Nursing, Baltimore, MD, USA.
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Kosho T, Kuniba H, Tanikawa Y, Hashimoto Y, Sakurai H. Natural history and parental experience of children with trisomy 18 based on a questionnaire given to a Japanese trisomy 18 parental support group. Am J Med Genet A 2013; 161A:1531-42. [DOI: 10.1002/ajmg.a.35990] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 03/19/2013] [Indexed: 11/12/2022]
Affiliation(s)
- Tomoki Kosho
- Department of Medical Genetics; Shinshu University School of Medicine; Matsumoto; Japan
| | - Hideo Kuniba
- Department of Pediatrics; Nagasaki University School of Medicine; Nagasaki; Japan
| | - Yuko Tanikawa
- Department of Nursing; Kobe City College of Nursing; Kobe; Japan
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Rosa RFM, Rosa RCM, Zen PRG, Graziadio C, Paskulin GA. Trissomia 18: revisão dos aspectos clínicos, etiológicos, prognósticos e éticos. REVISTA PAULISTA DE PEDIATRIA 2013; 31:111-20. [DOI: 10.1590/s0103-05822013000100018] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 05/21/2012] [Indexed: 12/21/2022]
Abstract
OBJETIVO: Revisar as características clínicas, etiológicas, diagnósticas e prognósticas da trissomia do cromossomo 18 (síndrome de Edwards). FONTES DE DADOS: Foram pesquisados artigos científicos presentes nos portais MedLine, Lilacs e SciELO, utilizando-se os descritores 'trisomy 18' e 'Edwards syndrome'. A pesquisa não se limitou a um período determinado e englobou artigos presentes nestes bancos de dados. SÍNTESE DOS DADOS: A síndrome de Edwards é uma doença caracterizada por um quadro clínico amplo e prognóstico bastante reservado. Há descrição na literatura de mais de 130 anomalias diferentes, as quais podem envolver praticamente todos os órgãos e sistemas. Seus achados são resultantes da presença de três cópias do cromossomo 18. A principal constituição cromossômica observada entre estes pacientes é a trissomia livre do cromossomo 18, que se associa ao fenômeno de não disjunção, especialmente na gametogênese materna. A maioria dos fetos com síndrome de Edwards acaba indo a óbito durante a vida embrionária e fetal. A mediana de sobrevida entre nascidos vivos tem usualmente variado entre 2,5 e 14,5 dias. CONCLUSÕES: O conhecimento do quadro clínico e do prognóstico dos pacientes com a síndrome de Edwards tem grande importância no que diz respeito aos cuidados neonatais e à decisão de instituir ou não tratamentos invasivos. A rapidez na confirmação do diagnóstico é importante para a tomada de decisões referentes às condutas médicas. Muitas vezes, as intervenções são realizadas em condições de emergência, sem muita oportunidade de reflexão ou discussão, e envolvem questões médicas e éticas difíceis.
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Boghossian NS, Horbar JD, Carpenter JH, Murray JC, Bell EF. Major chromosomal anomalies among very low birth weight infants in the Vermont Oxford Network. J Pediatr 2012; 160:774-780.e11. [PMID: 22177989 PMCID: PMC3646085 DOI: 10.1016/j.jpeds.2011.11.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Revised: 10/18/2011] [Accepted: 11/01/2011] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To examine prevalence, characteristics, interventions, and mortality of very low birth weight (VLBW) infants with trisomy 21 (T21), trisomy 18 (T18), trisomy 13 (T13), or triploidy. STUDY DESIGN Infants with birth weight 401-1500 g admitted to centers of the Vermont Oxford Network during 1994-2009 were studied. A majority of the analyses are presented as descriptive data. Median survival times and their 95% CIs were estimated using the Kaplan-Meier approach. RESULTS Of 539 509 VLBW infants, 1681 (0.31%) were diagnosed with T21, 1416 (0.26%) with T18, 435 (0.08%) with T13, and 116 (0.02%) with triploidy. Infants with T18 were the most likely to be growth restricted (79.7%). Major surgery was reported for 30.4% of infants with T21, 9.2% with T18, 6.4% with T13, and 4.8% with triploidy. Hospital mortality occurred among 33.1% of infants with T21, 89.0% with T18, 92.4% with T13, and 90.5% with triploidy. Median survival time was 4 days (95% CI, 3-4) among infants with T18 and 3 days (95% CI, 2-4) among both infants with T13 and infants with triploidy. CONCLUSION In this cohort of VLBW infants, survival among infants with T18, T13, or triploidy was very poor. This information can be used to counsel families.
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Affiliation(s)
| | - Jeffrey D. Horbar
- Vermont Oxford Network, Burlington, Vermont,Department of Pediatrics, University of Vermont, Burlington, Vermont
| | | | | | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
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Maeda J, Yamagishi H, Furutani Y, Kamisago M, Waragai T, Oana S, Kajino H, Matsuura H, Mori K, Matsuoka R, Nakanishi T. The impact of cardiac surgery in patients with trisomy 18 and trisomy 13 in Japan. Am J Med Genet A 2011; 155A:2641-6. [PMID: 21990245 DOI: 10.1002/ajmg.a.34285] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Accepted: 07/29/2011] [Indexed: 11/12/2022]
Abstract
Congenital heart defects (CHD) are very common in patients with trisomy 18 (T18) and trisomy 13 (T13). The surgical indication of CHD remains controversial since the natural history of these trisomies is documented to be poor. To investigate the outcome of CHD in patients with T18 and T13, we collected and evaluated clinical data from 134 patients with T18 and 27 patients with T13 through nationwide network of Japanese Society of Pediatric Cardiology and Cardiac Surgery. In patients with T18, 23 (17%) of 134 were alive at this survey. One hundred twenty-six (94%) of 134 patients had CHDs. The most common CHD was ventricular septal defect (VSD, 59%). Sixty-five (52%) of 126 patients with CHD developed pulmonary hypertension (PH). Thirty-two (25%) of 126 patients with CHD underwent cardiac surgery and 18 patients (56%) have survived beyond postoperative period. While palliative surgery was performed in most patients, six cases (19%) underwent intracardiac repair for VSD. Operated patients survived longer than those who did not have surgery (P < 0.01). In patients with T13, 5 (19%) of 27 patients were alive during study period. Twenty-three (85%) of 27 patients had CHD and 13 (57%) of 27 patients had PH. Atrial septal defect was the most common form of CHD (22%). Cardiac surgery was done in 6 (26%) of 23 patients. In this study, approximately a quarter of patients underwent surgery for CHD in both trisomies. Cardiac surgery may improve survival in selected patients with T18.
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Affiliation(s)
- Jun Maeda
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
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Abstract
OBJECTIVE The objective was to clarify the outcomes of cardiac surgery in trisomy 18 patients. PATIENTS AND METHODS We analysed 34 consecutive trisomy 18 patients, of whom 21 were males, with cardiac complications. They were divided into patients who underwent cardiac surgery and those who were conservatively treated. We compared rates of survival and discharge alive between two groups. RESULTS The surgery group included nine patients, with six males, who underwent cardiac surgery - intracardiac repair in three patients, pulmonary arterial banding in five patients, and ligation of the ductus in one patient - at median age of 2.2 months, ranging from 0.5 to 9.8, and with median weight of 2.6 kilograms, ranging from 1.5 to 3.2. Cardiac surgery and pre-operative assisted ventilation were hazardous factors leading to death. In the surgery group, cumulative survival rates at 1 month, 6 months, 12 months, and 24 months were 63%, 38%, 25%, and 22%, respectively, compared with 51%, 26%, 9%, and 9% in the conservative group. There was a significant difference (p = 0.002). The cumulative rates of discharge alive at 1 month, 3 months, and 6 months were 0%, 12%, and 65% in the surgery group, which did not differ from the conservative group (p = 0.80). CONCLUSIONS Cardiac surgery contributed to increased survival rate but not the rate of discharge alive in trisomy 18 patients. Cardiac surgery could not prevent all the trisomy 18 patients from death. The indication of cardiac surgery should be carefully individualised to improve the quality of life in trisomy 18 patients and concerned surrounding people.
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