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Sagar R, David AL. Fetal therapies - (Stem cell transplantation; enzyme replacement therapy; in utero genetic therapies). Best Pract Res Clin Obstet Gynaecol 2024; 97:102542. [PMID: 39298891 DOI: 10.1016/j.bpobgyn.2024.102542] [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: 08/06/2024] [Accepted: 09/02/2024] [Indexed: 09/22/2024]
Abstract
Advances in ultrasound and prenatal diagnosis are leading an expansion in the options for parents whose fetus is identified with a congenital disease. Obstetric diseases such as pre-eclampsia and fetal growth restriction may also be amenable to intervention to improve maternal and neonatal outcomes. Advanced Medicinal Therapeutic Products such as stem cell, gene, enzyme and protein therapies are most commonly being investigated as the trajectory of treatment for severe genetic diseases moves toward earlier intervention. Theoretical benefits include prevention of in utero damage, smaller treatment doses compared to postnatal intervention, use of fetal circulatory shunts and induction of immune tolerance. New systematic terminology can capture adverse maternal and fetal adverse events to improve safe trial conduct. First-in-human clinical trials are now beginning to generate results with a focus on safety first and efficacy second. If successful, these trials will transform the care of fetuses with severe early-onset congenital disease.
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Affiliation(s)
- Rachel Sagar
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, WC1E 6AU, UK.
| | - Anna L David
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, WC1E 6AU, UK; National Institute for Health and Care Research, University College London Hospitals NHS Foundation Trust Biomedical Research Centre, 149 Tottenham Court Road, London, W1T 7DN, UK.
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2
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Wilson S, Mehlhaff K. When Life Is Expected to Be Brief: A Case-Based Guide to Prenatal Collaborative Care. Neoreviews 2024; 25:e486-e496. [PMID: 39085172 DOI: 10.1542/neo.25-8-e486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 03/28/2024] [Accepted: 03/28/2024] [Indexed: 08/02/2024]
Abstract
Advances in fetal health detection and neonatal care have improved outcome predictions but have outpaced the development of treatments, leaving some families facing the heartbreaking reality of their baby's short life expectancy. Families with a fetus that has a life-limiting condition must make tough decisions, including the possibility of termination, perinatal palliative care options, and the extent of newborn resuscitation. Access to abortion services is crucial in decision-making, underscoring the significance of palliative care as an option. Perinatal palliative care programs offer vital support, honoring the baby and family throughout pregnancy, birth, and death. They provide compassionate care for pregnant individuals, partners, and newborns, integrating seamlessly into standard pregnancy and birth care. Successful programs prioritize families' desires, goals, and personal priorities, whether through a dedicated team or an organized system. "Regardless of the length of a baby's life or duration of illness, it is their lifetime. The infant and family deserve skilled and compassionate attention to their plight; a safety net throughout the experience; a palliative care approach emphasizing living fully those days, hours, and even moments." (1).
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Affiliation(s)
| | - Krista Mehlhaff
- Department of Maternal-Fetal Medicine, University of Maryland Medical Center, Baltimore, MD
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Galante N, Bedeschi MF, Beltrami B, Bailo P, Silva Palomino LA, Piccinini A. Reviewing hereditary connective tissue disorders: Proposals of harmonic medicolegal assessments. Int J Legal Med 2024:10.1007/s00414-024-03290-4. [PMID: 39008115 DOI: 10.1007/s00414-024-03290-4] [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: 03/12/2024] [Accepted: 07/09/2024] [Indexed: 07/16/2024]
Abstract
Hereditary connective tissue disorders (HCTDs) are a heterogeneous group of inherited diseases. These disorders show genetic mutations with loss of function of primary components of connective tissue, such as collagen and elastic fibers. There are more than 200 conditions that involve hereditary connective tissue disorders, while the most known are Marfan syndrome, Osteogenesis Imperfecta, and Ehlers-Danlos syndromes. These disorders need continuous updates, multidisciplinary skills, and specific methodologic evaluations sharing many medicolegal issues. Marfan syndrome and Ehlers-Danlos syndromes show a high risk of early sudden death. As a consequence of this, postmortem genetic testing can identify novel genotype-phenotype correlations which help the clinicians to assess personalized cardiovascular screening programs among the ill subjects. Genetic testing is also essential to identify children suffering from Osteogenesis Imperfecta, especially when a physical abuse is clinically suspected. However, this is a well-known clinical problem even though there are still challenges to interpret genetic data and variants of unknown significance due to the current extensive use of new genetic/genomic techniques. Additionally, the more significant applications and complexities of genomic testing raise novel responsibilities on the clinicians, geneticists, and forensic practitioners as well, increasing potential liability and medical malpractice claims. This systematic review provides a detailed overview on how multidisciplinary skills belonging to clinicians, medicolegal consultants, radiologists, and geneticists can cooperate to manage HCTDs from autopsy or clinical findings to genetic testing. Thus, technical aspects need to be addressed to the medicolegal community since there is no consensus works or guidelines which specifically discuss these issues.
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Affiliation(s)
- Nicola Galante
- Section of Legal Medicine of Milan, University of Milan, Via Luigi Mangiagalli 37, 20133, Milan, Italy.
- Department of Biomedical Sciences for Health, University of Milan, Via Luigi Mangiagalli 37, 20133, Milan, Italy.
| | | | - Benedetta Beltrami
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Medical Genetic Unit, Milan, Italy
| | - Paolo Bailo
- Section of Legal Medicine of Milan, University of Milan, Via Luigi Mangiagalli 37, 20133, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Via Luigi Mangiagalli 37, 20133, Milan, Italy
| | | | - Andrea Piccinini
- Section of Legal Medicine of Milan, University of Milan, Via Luigi Mangiagalli 37, 20133, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Via Luigi Mangiagalli 37, 20133, Milan, Italy
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Sagar RL, Åström E, Chitty LS, Crowe B, David AL, DeVile C, Forsmark A, Franzen V, Hermeren G, Hill M, Johansson M, Lindemans C, Lindgren P, Nijhuis W, Oepkes D, Rehberg M, Sahlin NE, Sakkers R, Semler O, Sundin M, Walther-Jallow L, Verweij EJTJ, Westgren M, Götherström C. An exploratory open-label multicentre phase I/II trial evaluating the safety and efficacy of postnatal or prenatal and postnatal administration of allogeneic expanded fetal mesenchymal stem cells for the treatment of severe osteogenesis imperfecta in infants and fetuses: the BOOSTB4 trial protocol. BMJ Open 2024; 14:e079767. [PMID: 38834319 PMCID: PMC11163617 DOI: 10.1136/bmjopen-2023-079767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 05/22/2024] [Indexed: 06/06/2024] Open
Abstract
INTRODUCTION Severe osteogenesis imperfecta (OI) is a debilitating disease with no cure or sufficiently effective treatment. Mesenchymal stem cells (MSCs) have good safety profile, show promising effects and can form bone. The Boost Brittle Bones Before Birth (BOOSTB4) trial evaluates administration of allogeneic expanded human first trimester fetal liver MSCs (BOOST cells) for OI type 3 or severe type 4. METHODS AND ANALYSIS BOOSTB4 is an exploratory, open-label, multiple dose, phase I/II clinical trial evaluating safety and efficacy of postnatal (n=15) or prenatal and postnatal (n=3, originally n=15) administration of BOOST cells for the treatment of severe OI compared with a combination of historical (1-5/subject) and untreated prospective controls (≤30). Infants<18 months of age (originally<12 months) and singleton pregnant women whose fetus has severe OI with confirmed glycine substitution in COL1A1 or COL1A2 can be included in the trial.Each subject receives four intravenous doses of 3×106/kg BOOST cells at 4 month intervals, with 48 (doses 1-2) or 24 (doses 3-4) hours in-patient follow-up, primary follow-up at 6 and 12 months after the last dose and long-term follow-up yearly until 10 years after the first dose. Prenatal subjects receive the first dose via ultrasound-guided injection into the umbilical vein within the fetal liver (16+0 to 35+6 weeks), and three doses postnatally.The primary outcome measures are safety and tolerability of repeated BOOST cell administration. The secondary outcome measures are number of fractures from baseline to primary and long-term follow-up, growth, change in bone mineral density, clinical OI status and biochemical bone turnover. ETHICS AND DISSEMINATION The trial is approved by Competent Authorities in Sweden, the UK and the Netherlands (postnatal only). Results from the trial will be disseminated via CTIS, ClinicalTrials.gov and in scientific open-access scientific journals. TRIAL REGISTRATION NUMBERS EudraCT 2015-003699-60, EUCT: 2023-504593-38-00, NCT03706482.
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Affiliation(s)
- Rachel L Sagar
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Eva Åström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Lyn S Chitty
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Genetics and Genomics, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Belinda Crowe
- Department of Neurosciences, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Anna L David
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Catherine DeVile
- Department of Neurosciences, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | | | - Göran Hermeren
- Department of Clinical Sciences, Lund University Faculty of Medicine, Lund, Sweden
| | - Melissa Hill
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Genetics and Genomics, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Mats Johansson
- Department of Clinical Sciences, Lund University Faculty of Medicine, Lund, Sweden
| | - Caroline Lindemans
- Department of Pediatrics, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Peter Lindgren
- Center for Fetal Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Wouter Nijhuis
- Department of Orthopedic Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Mirko Rehberg
- Department of Pediatrics, University Hospital Cologne, Koln, Nordrhein-Westfalen, Germany
| | - Nils-Eric Sahlin
- Department of Clinical Sciences, Lund University Faculty of Medicine, Lund, Sweden
| | - Ralph Sakkers
- Department of Orthopedic Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - O Semler
- Department of Pediatrics, University Hospital Cologne, Koln, Nordrhein-Westfalen, Germany
| | - Mikael Sundin
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Section of Pediatic Hematology, Immunology and HCT, Karolinska University Hospital, Stockholm, Sweden
| | - Lilian Walther-Jallow
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - E J T Joanne Verweij
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Magnus Westgren
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Götherström
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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Arundel P, Borg SA. Early Life Management of Osteogenesis Imperfecta. Curr Osteoporos Rep 2023; 21:779-786. [PMID: 37752354 PMCID: PMC10724332 DOI: 10.1007/s11914-023-00823-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 09/28/2023]
Abstract
PURPOSE OF REVIEW This review aims to provide a review of the multidisciplinary management of infants with osteogenesis imperfecta (OI) during the first year of life, focusing on those with severe disease. The authors draw on published literature and direct experience of working in a large paediatric centre specialising in the management of rare bone disease. RECENT FINDINGS Whilst understanding of the pathophysiology of OI has grown over the past decade, the evidence base for management of infants remains limited. There has been a greater recognition of certain subjects of concern including pain management, cervical spine deformity, and neurocognitive development. Both international consensus guidelines on rehabilitation and disease-specific growth charts have been welcomed by clinical teams. The early involvement of multidisciplinary specialist care is critical in ensuring optimal care for the infant with severe OI. A long-term perspective which focuses on the axial, craniofacial, and peripheral skeleton as well as on development more generally provides a framework which can guide the management of infants with severe OI.
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Affiliation(s)
- Paul Arundel
- Sheffield Children's NHS Foundation Trust, Sheffield, UK.
- Highly Specialised Service for Complex Childhood Osteogenesis Imperfecta, NHS England, London, UK.
| | - Stephanie A Borg
- Sheffield Children's NHS Foundation Trust, Sheffield, UK
- Highly Specialised Service for Complex Childhood Osteogenesis Imperfecta, NHS England, London, UK
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Wang YW, Carnevale FA, Ezcurra M, Chougui K, Bilodeau C, Siedlikowski S, Tsimicalis A. The moral experiences of children with osteogenesis imperfecta. Nurs Ethics 2022; 29:1773-1791. [PMID: 35801828 DOI: 10.1177/09697330221105635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Serious ethical problems have been anecdotally identified in the care of children with osteogenesis imperfecta (OI), which may negatively impact their moral experiences, defined as their sense of fulfillment towards personal values and beliefs. RESEARCH AIMS To explore children's actual and desired participation in discussions, decisions, and actions in an OI hospital setting and their community using art-making to facilitate their self-expression. RESEARCH DESIGN A focused ethnography was conducted using the moral experiences framework with data from key informant interviews; participant observations, semi-structured interviews, and practice-based research (art-making) with 10 children with OI; and local documents. PARTICIPANTS AND RESEARCH CONTEXT The study was conducted at a pediatric, orthopedic hospital. ETHICAL CONSIDERATIONS This study was approved by McGill University Institutional Review Board. FINDINGS/RESULTS Children expressed desires to participate in their care, but sometimes lacked the necessary resources and encouragement from healthcare providers. Art-making facilitated children's voice and participation in health-related discussions. CONCLUSIONS Healthcare providers are recommended to consider the benefits of art-making and educational resources to reduce discrepancies between children's actual and desired participation in care and promote positive moral experiences.
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Affiliation(s)
- Yi Wen Wang
- 5620McGill University, Canada.,70357Shriners Hospital for Children®-Canada, Canada
| | - Franco A Carnevale
- 5620McGill University, Canada.,70357Shriners Hospital for Children®-Canada, Canada
| | - Maria Ezcurra
- 5620McGill University, Canada.,70357Shriners Hospital for Children®-Canada, Canada
| | | | | | - Sophia Siedlikowski
- 5620McGill University, Canada.,70357Shriners Hospital for Children®-Canada, Canada
| | - Argerie Tsimicalis
- 5620McGill University, Canada.,70357Shriners Hospital for Children®-Canada, Canada
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7
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Humphrey LM, Schlegel AB. Longitudinal Perinatal Palliative Care for Severe Fetal Neurologic Diagnoses. Semin Pediatr Neurol 2022; 42:100965. [PMID: 35868733 DOI: 10.1016/j.spen.2022.100965] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/23/2022] [Accepted: 03/24/2022] [Indexed: 11/30/2022]
Abstract
Perinatal palliative care (PnPC) focuses on enhancing family and newborn quality-of-life in the setting of a life-limiting fetal condition while simultaneously ensuring medical care delivery that is soundly in line with the family's goals and values. The inclusion of PnPC in the multidisciplinary care of a family facing severe fetal neurologic diagnoses allows for skilled exploration of the values and experience that ultimately drive creation of goals of care. The parental experience of receiving a life-limiting fetal diagnosis pushes parents into an emotional journey, which typically follows a recognizable progression of stages. PnPC providers appreciate the significance of this experiential journey and the importance of parental movement toward readiness to simultaneously welcome and mourn their child. Through longitudinal supportive care, beginning early in the fetal diagnostic progress and continuing throughout pregnancy and into the newborn period, PnPC providers explore the uncharted parental experience alongside the family and support them in creating value-driven care plans for their child. They contribute greatly to the multidisciplinary fetal and neonatal care teams as the advocate for and promote insightful communication and assist in delivery and coordination of value-driven care.
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Affiliation(s)
- Lisa M Humphrey
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH; Section of Hospice and Palliative Care, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University School of Medicine, Columbus, OH
| | - Amy B Schlegel
- Department of Pediatrics, The Ohio State University School of Medicine, Columbus, OH; Division of Neonatology, Nationwide Children's Hospital, Columbus, OH.
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Abstract
OBJECTIVE/METHODS Pediatric Palliative Care (PPC) is a multidisciplinary medical subspecialty focused on the care of children with serious illnesses and terminal diagnoses. Providers impact the care of children from the perinatal stage through adolescence/young adulthood and help patients and families face diagnoses such as complex chronic disease and malignancy. This article describes these unique populations and distinct areas of current PPC research. RESULTS Unique aspects of PPC include a high level of prognostic uncertainty, symptom burden, pediatric, and surrogate advance care planning, hope in the face of prognostic challenges, care of children at end of life, concurrent care, staff support, sibling support, and bereavement. CONCLUSION PPC's evolution from an extension of hospice into a continuum of support for families and staff caring for children with serious illnesses is exemplified in both qualitative and quantitative research. The literature proves the value that PPC can provide to families, hospitals, and communities. PPC is evolving from a supportive service into a uniquely beneficial, collaborative, educational, and interdisciplinary specialty that improves outcomes for all involved.Plain Language Summary (PLS)Pediatric Palliative Care (PPC) is a service provided to all children with serious illness as a way of addressing suffering. Populations served by PPC range from those not yet born to patients preparing for adulthood. The serious illnesses they face range from chronic disease to cancer. Over the last 20 years research has explored the unique aspects of the pediatric experience of serious illness, including prognostic uncertainty, concurrent care, symptom management, advance care planning, hope, family experience of illness, care at the end of life, staff support, and bereavement.As the number of patients who would benefit from PPC services rapidly expands nationally and worldwide, PPC teams provide education and skills training for their colleagues in primary and subspecialty fields. Hospitals benefit from PPC through improved patient experience, family-centered care, and staff support. Communities are served by PPC that occurs in and out of the hospital.Research in PPC provides guidance for challenging questions in care and has resulted in an increasingly robust body of work. PPC providers have skills of advanced communication training, hope in the face of uncertainty, targeted and personalized symptom management, and a diverse understanding of quality of life. These skills help support decision-making and establish strong connections between providers and families.The field of PPC has a distinct skillset to support families who face serious illness. This article helps medical and psychosocial providers visualize how PPC is evolving from what has often been explained to families as an added layer of support into a uniquely beneficial, collaborative, and interdisciplinary service.
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Affiliation(s)
- Benjamin Moresco
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Dominic Moore
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
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9
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Blackshaw BP, Hendricks P. Fine-tuning the impairment argument. JOURNAL OF MEDICAL ETHICS 2021; 47:641-642. [PMID: 33172908 DOI: 10.1136/medethics-2020-106904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/05/2020] [Accepted: 10/12/2020] [Indexed: 06/11/2023]
Abstract
Perry Hendricks' original impairment argument for the immorality of abortion is based on the impairment principle: if impairing an organism to some degree is immoral, then ceteris paribus, impairing it to a higher degree is also immoral. Since abortion impairs a fetus to a higher degree than fetal alcohol syndrome (FAS) and giving a fetus FAS is immoral, it follows that abortion is immoral. Critics have argued that the ceteris paribus is not met for FAS and abortion, and so we proposed the modified impairment principle (MIP) to avoid these difficulties. Dustin Crummett has responded, arguing that MIP is open to various counterexamples which show it to be false. He also shows that MIP can generate moral dilemmas. Here, we propose a modification to MIP that resolves the issues Crummett raises. Additionally, Alex Gillham has criticised our appropriation of Don Marquis' 'future like ours' reasoning about the wrongness of impairment. We show that his objections have minimal implications for our argument.
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Affiliation(s)
| | - Perry Hendricks
- Department of Philosophy, Purdue University, West Lafayette, Indiana, USA
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10
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Sotoudeh Anvari M, Gharib A, Abolhasani M, Azari-Yam A, Hossieni Gharalari F, Safavi M, Zare Mirzaie A, Vasei M. Pre-analytical Practices in the Molecular Diagnostic Tests, A Concise Review. IRANIAN JOURNAL OF PATHOLOGY 2020; 16:1-19. [PMID: 33391375 PMCID: PMC7691716 DOI: 10.30699/ijp.2020.124315.2357] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 07/05/2020] [Indexed: 12/17/2022]
Abstract
Molecular assays for detection of nucleic acids in biologic specimens are valuable diagnostic tools supporting clinical diagnoses and therapeutic decisions. Pre-analytical errors, which occur before or during processing of nucleic acid extraction, contribute a significant role in common errors that take place in molecular laboratories. Certain practices in specimen collection, transportation, and storage can affect the integrity of nucleic acids before analysis. Applying best practices in these steps, helps to minimize those errors and leads to better decisions in patient diagnosis and treatment. Widely acceptable recommendations, which are for optimal molecular assays associated with pre-analytic variables, are limited. In this article, we have reviewed most of the important issues in sample handling from bed to bench before starting molecular tests, which can be used in diagnostic as well as research laboratories. We have addressed the most important pre-analytical points in performing molecular analysis in fixed and unfixed solid tissues, whole blood, serum, plasma, as well as most of the body fluids including urine, fecal and bronchial samples, as well as prenatal diagnosis samples.
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Affiliation(s)
- Maryam Sotoudeh Anvari
- Molecular Pathology and Cytogenetics Division, Pathology Department, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Atoosa Gharib
- Department of Pathology, Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Abolhasani
- Oncopathology Research Center, Iran University of Medical Sciences (IUMS), Tehran, Iran; Hasheminejad Kidney Center, Iran University of Medical Sciences, Tehran, Iran
| | - Aileen Azari-Yam
- Molecular Pathology and Cytogenetics Division, Pathology Department, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Moeinadin Safavi
- Molecular Pathology and Cytogenetics Division, Pathology Department, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Zare Mirzaie
- Department of Pathology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Vasei
- Cell-based Therapies Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Muensterer OJ, Paul NW. Über die Problematik der klinischen Entscheidungsfindung aufgrund von Fallbeschreibungen – ethische Implikationen am Beispiel eines Falls von Carmi Syndrom. Ethik Med 2020. [DOI: 10.1007/s00481-020-00591-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ZusammenfassungBei extrem seltenen Erkrankungen bilden Fallbeschreibungen oft die einzige Datengrundlage für klinische Entscheidungen. Das Carmi Syndrom ist eine seltene Kombination von Epidermolysis bullosa und Pylorusatresie. Während der Betreuung einer betroffenen Patientin fielen unterschiedliche Wahrnehmungen über die publizierten Mortalitätsraten auf. Daraufhin wurde die Hypothese untersucht, ob sich die kumulativen Mortalitätsraten von Einzelfallbeschreibungen und Mehrfachfallbeschreibungen unterscheiden, um so eine mögliche Verzerrung der Prognose in ihren Auswirkungen auf klinische und ethische Einschätzungen des Falls zu überprüfen.Ein Mädchen wurde in der Schwangerschaftswoche 33 mit Carmi Syndrom geboren. Zusammen mit dem klinischen Ethikkomitee wurden Behandlungsoptionen diskutiert, einschließlich einer palliativen Behandlung oder einer operativen Gastrojejunostomie. Da etwa ein Drittel der in Fallbeschreibungen publizierten Kinder nach einer Operation überlebten, entschieden wir uns auch vor dem Hintergrund unsicherer Prognosen für das chirurgische Vorgehen. Die Patientin starb 4 Wochen später nach multiplen Komplikationen.Die Datenbank PubMed wurde nach Publikationen über Carmi Syndrom durchsucht. Das Outcome von Einzelfallbeschreibungen wurde mit dem von Mehrfachfallbeschreibungen verglichen.Insgesamt wurden 102 Fälle von Carmi Syndrom identifiziert. Die Mortalität bei Einzelfallbeschreibungen belief sich auf 17 von 27 Fällen (63 %), während 62 von 74 Patienten von Mehrfachfallbeschreibungen starben (84 %, p = 0,036).Beim Carmi Syndrom unterscheidet sich die publizierte Mortalität zwischen Einfach- und Mehrfachfallbeschreibungen, möglicherweise aufgrund einer Kombination von Selektions- und Publikationsbias. Die Unterschätzung der tatsächlichen Mortalitätsrate kann zu unangebracht intensiven Therapieansätzen führen. Kliniker und Ethiker sollten daher vorsichtig sein, ihre Entscheidungen bei seltenen oder neuartigen Erkrankungen auf kumulative Erfahrungen von Fallbeschreibungen, insbesondere von Einzelfallbeschreibungen, zu basieren, die positive Verläufe von Behandlungen zu betonen scheinen.
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12
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Garten L, von der Hude K, Strahleck T, Krones T. Extending the Concept of Advance Care Planning to the Perinatal Period. KLINISCHE PADIATRIE 2020; 232:249-256. [PMID: 32542620 DOI: 10.1055/a-1179-0530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Easier access to prenatal diagnostic procedures led to its widespread use as a screening measure. Hence, today it is more common for life-limiting illnesses to be diagnosed during fetal life. The concept of Advance Care Planning (ACP) provides a framework for caregivers, families and their multidisciplinary teams to anticipate and plan ahead for potential future medical decisions so that the affected children are reliably treated according to their parents' individual values and wishes. In the perinatal context, ACP also has the potential to tackle the needs of unborn or newborn children with life-limiting illnesses and their families better, avoid unnecessary and burdensome measures and focus upon goals that are valuable and meaningful to both child and family.
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Affiliation(s)
- Lars Garten
- Neonatology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Thomas Strahleck
- Department of Neonatology and Neonatal Intensive Care, Klinikum Stuttgart-Olgahospital, Stuttgart, Germany
| | - Tanja Krones
- Institute of Biomedical Ethics and History of Medicine University of Zürich, University Hospital Zürich, Zürich, Switzerland
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Perinatal Counseling Following a Diagnosis of Trisomy 13 or 18: Incorporating the Facts, Parental Values, and Maintaining Choices. Adv Neonatal Care 2020; 20:204-215. [PMID: 31996562 DOI: 10.1097/anc.0000000000000704] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Families with a prenatal diagnosis of trisomy 13 or 18 are told many things, some true and some myths. They present with differing choices on how to proceed that may or may not be completely informed. PURPOSE To provide the prenatal counselor with a review of the pertinent obstetrical and neonatal outcome data and ethical discussion to help them in supporting families with the correct information for counseling. METHODS/SEARCH STRATEGY This article provides a review of the literature on facts and myths and provides reasonable outcome data to help families in decision making. FINDINGS/RESULTS These disorders comprise a heterogeneous group regarding presentation, outcomes, and parental goals. The authors maintain that there needs to be balanced decision-making between parents and providers for the appropriate care for the woman and her infant. IMPLICATIONS FOR PRACTICE Awareness of this literature can help ensure that prenatal and palliative care consultation incorporates the appropriate facts and parental values and in the end supports differing choices that can support the infant's interests.
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Zhytnik L, Simm K, Salumets A, Peters M, Märtson A, Maasalu K. Reproductive options for families at risk of Osteogenesis Imperfecta: a review. Orphanet J Rare Dis 2020; 15:128. [PMID: 32460820 PMCID: PMC7251694 DOI: 10.1186/s13023-020-01404-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 05/11/2020] [Indexed: 02/07/2023] Open
Abstract
Background Osteogenesis Imperfecta (OI) is a rare genetic disorder involving bone fragility. OI patients typically suffer from numerous fractures, skeletal deformities, shortness of stature and hearing loss. The disorder is characterised by genetic and clinical heterogeneity. Pathogenic variants in more than 20 different genes can lead to OI, and phenotypes can range from mild to lethal forms. As a genetic disorder which undoubtedly affects quality of life, OI significantly alters the reproductive confidence of families at risk. The current review describes a selection of the latest reproductive approaches which may be suitable for prospective parents faced with a risk of OI. The aim of the review is to alleviate suffering in relation to family planning around OI, by enabling prospective parents to make informed and independent decisions. Main body The current review provides a comprehensive overview of possible reproductive options for people with OI and for unaffected carriers of OI pathogenic genetic variants. The review considers reproductive options across all phases of family planning, including pre-pregnancy, fertilisation, pregnancy, and post-pregnancy. Special attention is given to the more modern techniques of assisted reproduction, such as preconception carrier screening, preimplantation genetic testing for monogenic diseases and non-invasive prenatal testing. The review outlines the methodologies of the different reproductive approaches available to OI families and highlights their advantages and disadvantages. These are presented as a decision tree, which takes into account the autosomal dominant and autosomal recessive nature of the OI variants, and the OI-related risks of people without OI. The complex process of decision-making around OI reproductive options is also discussed from an ethical perspective. Conclusion The rapid development of molecular techniques has led to the availability of a wide variety of reproductive options for prospective parents faced with a risk of OI. However, such options may raise ethical concerns in terms of methodologies, choice management and good clinical practice in reproductive care, which are yet to be fully addressed.
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Affiliation(s)
- Lidiia Zhytnik
- Clinic of Traumatology and Orthopaedics, Tartu University Hospital, Tartu, Estonia.
| | - Kadri Simm
- Institute of Philosophy and Semiotics, Faculty of Arts and Humanities, University of Tartu, Tartu, Estonia.,Centre of Ethics, University of Tartu, Tartu, Estonia
| | - Andres Salumets
- Competence Centre on Health Technologies, Tartu, Estonia.,Department of Obstetrics and Gynaecology, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.,Institute of Genomics, University of Tartu, Tartu, Estonia.,COMBIVET ERA Chair, Institute of Veterinary Medicine and Animal Sciences, Estonian University of Life Sciences, Tartu, Estonia
| | - Maire Peters
- Competence Centre on Health Technologies, Tartu, Estonia.,Department of Obstetrics and Gynaecology, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Aare Märtson
- Clinic of Traumatology and Orthopaedics, Tartu University Hospital, Tartu, Estonia.,Department of Traumatology and Orthopaedics, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Katre Maasalu
- Clinic of Traumatology and Orthopaedics, Tartu University Hospital, Tartu, Estonia.,Department of Traumatology and Orthopaedics, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
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Abstract
Perinatal palliative care refers to a coordinated care strategy that comprises options for obstetric and newborn care that include a focus on maximizing quality of life and comfort for newborns with a variety of conditions considered to be life-limiting in early infancy. With a dual focus on ameliorating suffering and honoring patient values, perinatal palliative care can be provided concurrently with life-prolonging treatment. The focus of this document, however, involves the provision of exclusively palliative care without intent to prolong life in the context of a life-limiting condition, otherwise known as perinatal palliative comfort care. Once a life-limiting diagnosis is suspected antenatally, the tenets of informed consent require that the pregnant patient be given information of sufficient depth and breadth to make an informed, voluntary choice for her care. Health care providers are encouraged to model effective, compassionate communication that respects patient cultural beliefs and values and to promote shared decision making with patients. Perinatal palliative comfort care is one of several options along a spectrum of care, which includes pregnancy termination (abortion) and full neonatal resuscitation and treatment, that should be presented to pregnant patients faced with pregnancies complicated by life-limiting fetal conditions. If a patient opts to pursue perinatal palliative comfort care, a multidisciplinary team should be identified with the infrastructure and support to administer this care. The perinatal palliative care team should prepare families for the possibility that there may be differences of opinion between family members before and after the delivery of the infant, and that there may be differences between parents and the neonatal care providers about appropriate postnatal therapies, especially if the postnatal diagnosis and prognosis differ substantially from antenatal predictions. Procedures for resolving such differences should be discussed with families ahead of time.
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Garten L, Globisch M, von der Hude K, Jäkel K, Knochel K, Krones T, Nicin T, Offermann F, Schindler M, Schneider U, Schubert B, Strahleck T. Palliative Care and Grief Counseling in Peri- and Neonatology: Recommendations From the German PaluTiN Group. Front Pediatr 2020; 8:67. [PMID: 32181234 PMCID: PMC7058113 DOI: 10.3389/fped.2020.00067] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 02/11/2020] [Indexed: 12/02/2022] Open
Affiliation(s)
- Lars Garten
- Department of Neonatology, Palliative Neonatology Team, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Marcel Globisch
- Department for Content and Development, German Children's Hospice Association, Olpe, Germany
| | - Kerstin von der Hude
- Department of Neonatology, Palliative Neonatology Team, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Karin Jäkel
- Association of Premature and At-Risk Born Children, Regional group of Rhineland-Palatinate, Mainz, Germany
| | - Kathrin Knochel
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Tanja Krones
- University Hospital Zürich/Institute of Biomedical Ethics and History of Medicine, University of Zürich, Zurich, Switzerland
| | - Tatjana Nicin
- Department of Obstetrics, Klinikum Hanau, Hanau, Germany
| | - Franziska Offermann
- Federal Association of Orphaned Parents and Mourning Siblings in Germany, Leipzig, Germany
| | - Monika Schindler
- Department of Neonatology and Paediatric Intensive Care, Universitätsklinikum Mannheim, Mannheim, Germany
| | - Uwe Schneider
- Department of Obstetrics, Universitätsklinikum Jena, Jena, Germany
| | - Beatrix Schubert
- Roman-Catholic Diocese of Rottenburg-Stuttgart, Department Pastoral Care in Health Care, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Thomas Strahleck
- Department of Neonatology and Neonatal Intensive Care, Klinikum Stuttgart, Olgahospital, Stuttgart, Germany
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Baker A, Lagatta J, Leuthner S, Acharya K. Does prenatal counseling for pregnancies complicated by multiple fetal abnormalities concord with postnatal outcomes? Prenat Diagn 2020; 40:538-548. [PMID: 31913526 DOI: 10.1002/pd.5636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/15/2019] [Accepted: 12/14/2019] [Indexed: 11/07/2022]
Abstract
OBJECTIVE In pregnancies complicated by multiple fetal abnormalities, our objective was to determine the degree of concordance between prenatal prognosis and postnatal outcomes. METHOD Retrospective cohort study of pregnancies with multiple fetal abnormalities referred to the Fetal Concerns Center of Wisconsin (FCCW) from 2015 to 2018. We reviewed records for anomalies, given prognostic severity, and postnatal outcomes. Prognostic severity was categorized as "likely mortality," "severe impairment," "moderate," and "mild" based on predetermined criteria. RESULTS In 85 pregnancies with multiple fetal abnormalities, 48% were given a prognosis of "likely mortality," and 19% were given a prognosis of "severe impairment." In pregnancies that were continued after being counseled as "likely mortality," this outcome was concordant in all but one case, despite medical interventions. In pregnancies counseled as "severe impairment," the more common outcome was mortality or severe impairment in 88% of cases and survival with severe impairment in 33% of cases. Postnatal outcomes were concordant with prenatal severity in 68% of the cases, more severe in 20% of the cases, and less severe in fewer than 5% of cases. CONCLUSION Prenatal predictions about severe outcomes are usually true in pregnancies complicated by multiple abnormalities. In cases of outcome discordance, outcomes tend to be more severe than predicted.
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Affiliation(s)
- Anna Baker
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Joanne Lagatta
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Steven Leuthner
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Krishna Acharya
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
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Mendes J, Wool J, Wool C. Ethical Considerations in Perinatal Palliative Care. J Obstet Gynecol Neonatal Nurs 2017; 46:367-377. [DOI: 10.1016/j.jogn.2017.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2017] [Indexed: 10/19/2022] Open
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Pfeifer U, Gubler D, Bergstraesser E, Bassler D. Congenital malformations, palliative care and postnatal redirection to more intensive treatment - a review at a Swiss tertiary center. J Matern Fetal Neonatal Med 2017; 31:1182-1187. [PMID: 28413896 DOI: 10.1080/14767058.2017.1311317] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE The so-called lethal malformations pose ethical challenges. Most affected fetuses die before or at birth. Live-born neonates commonly receive palliative care. If the postnatal course is better than expected, redirection towards more treatment may occur. We aimed to analyze this in a Swiss patient cohort. MATERIALS AND METHODS Over 6 years, fetal malformation was suspected in 1113 cases. We identified patients prenatally assigned to palliative care, assessed pre- and postnatal diagnoses, and outcomes. RESULTS Fourteen neonates received palliative care. Eleven patients received palliative care following late termination of pregnancy, for three, palliative care was planned and the fetus died during delivery, for two, the outcome was unknown (incomplete documentation). Genetic testing was performed in 50%. The predominant diagnostic group was central nervous system malformations (33%), followed by chromosomal aberrations (20%) and renal anomalies (17%). One child assigned to palliative care was resuscitated. Antenatal findings were anhydramnios and pulmonary hypoplasia. Postnatally, respiration was better than expected. The neonate was admitted to intensive care, died on day one. CONCLUSIONS Nervous system malformations seem to be a major criterion for foregoing life-sustaining interventions. Redirection towards more treatment is rare. This may reflect precise prenatal prognostication; a degree of self-fulfilling prophecy cannot be excluded.
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Affiliation(s)
- Ulrich Pfeifer
- a Department of Neonatology , University Hospital Zurich, University of Zurich , Zurich , Switzerland
| | - Deborah Gubler
- a Department of Neonatology , University Hospital Zurich, University of Zurich , Zurich , Switzerland
| | - Eva Bergstraesser
- b Pediatric Palliative Care , University Children's Hospital Zurich, University of Zurich , Zurich , Switzerland
| | - Dirk Bassler
- a Department of Neonatology , University Hospital Zurich, University of Zurich , Zurich , Switzerland
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