Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Microbe-mediated intestinal NOD2 stimulation improves linear growth of undernourished infant mice

The intestinal microbiota is known to influence postnatal growth. We previously found that a strain of Lactiplantibacillus plantarum (strain Lp^WJL) buffers the adverse effects of chronic undernutrition on the growth of juvenile germ-free mice. Here, we report that Lp^WJL sustains the postnatal growth of malnourished conventional animals and supports both insulin-like growth factor-1 (IGF-1) and insulin production and activity. We have identified cell walls isolated from Lp^WJL, as well as muramyl dipeptide and mifamurtide, as sufficient cues to stimulate animal growth despite undernutrition. Further, we found that NOD2 is necessary in intestinal epithelial cells for Lp^WJL-mediated IGF-1 production and for postnatal growth promotion in malnourished conventional animals. These findings indicate that, coupled with renutrition, bacteria cell walls or purified NOD2 ligands have the potential to alleviate stunting.

Incidence and associated factors of cetuximab-induced hypersensitivity infusion reactions in 1392 cancer patients treated in four French areas: a possible association with Lyme disease?

BACKGROUND

Previous studies have observed an increased incidence of Cetuximab-induced hypersensitivity infusion reactions (CI-IRs) in the southeastern states of the USA. Tick's bites were suspected of generating cross-reactions between cetuximab and alpha-gal. This study aims was to describe the incidence and associated risk factors of CI-IRs, in the French areas chosen according to their Lyme disease incidence.

PATIENTS AND METHODS

A retrospective chart review was conducted on patients that received cetuximab infusion from January 2010 to June 2019 in 4 French areas with different Lyme disease incidence rates.

RESULTS

Of 1392 patients, 117 (8.4%) experienced a CI-IR, including 68 severe (grade 3 or 4) reactions (4.9%). This CI-IR incidence was significantly higher in the Lyme disease high-risk area than in the other areas (13.2% versus 7.1%, 8.1% and 6.4%; P = 0.016). Sex (P = 0.53), premedication (P = 0.91), primary cancer location (P = 0.46) and chemotherapy regimen type (P = 0.78) had no impact on CI-IR incidence in the overall population. In the head and neck squamous cell carcinoma (HNSCC) patient subgroup, CI-IRs were significantly more frequent in the high-risk area (16.4% versus 6.7%, 7.1% and 7.0%; P = 0.0015).

CONCLUSION

This study suggests that patients treated in the French area with the highest incidence of Lyme disease are at a higher risk of CI-IRs.

The Hunga Tonga-Hunga Ha'apai Hydration of the Stratosphere

Following the 15 January 2022 Hunga Tonga-Hunga Ha'apai eruption, several trace gases measured by the Aura Microwave Limb Sounder (MLS) displayed anomalous stratospheric values. Trajectories and radiance simulations confirm that the H₂O, SO₂, and HCl enhancements were injected by the eruption. In comparison with those from previous eruptions, the SO₂ and HCl mass injections were unexceptional, although they reached higher altitudes. In contrast, the H₂O injection was unprecedented in both magnitude (far exceeding any previous values in the 17-year MLS record) and altitude (penetrating into the mesosphere). We estimate the mass of H₂O injected into the stratosphere to be 146 ± 5 Tg, or ∼10% of the stratospheric burden. It may take several years for the H₂O plume to dissipate. This eruption could impact climate not through surface cooling due to sulfate aerosols, but rather through surface warming due to the radiative forcing from the excess stratospheric H₂O.

The Hunga Tonga-Hunga Ha'apai Hydration of the Stratosphere

Following the 15 January 2022 Hunga Tonga-Hunga Ha'apai eruption, several trace gases measured by the Aura Microwave Limb Sounder (MLS) displayed anomalous stratospheric values. Trajectories and radiance simulations confirm that the H₂O, SO₂, and HCl enhancements were injected by the eruption. In comparison with those from previous eruptions, the SO₂ and HCl mass injections were unexceptional, although they reached higher altitudes. In contrast, the H₂O injection was unprecedented in both magnitude (far exceeding any previous values in the 17-year MLS record) and altitude (penetrating into the mesosphere). We estimate the mass of H₂O injected into the stratosphere to be 146 ± 5 Tg, or ∼10% of the stratospheric burden. It may take several years for the H₂O plume to dissipate. This eruption could impact climate not through surface cooling due to sulfate aerosols, but rather through surface warming due to the radiative forcing from the excess stratospheric H₂O.

The Hunga Tonga-Hunga Ha'apai Hydration of the Stratosphere

Following the 15 January 2022 Hunga Tonga-Hunga Ha'apai eruption, several trace gases measured by the Aura Microwave Limb Sounder (MLS) displayed anomalous stratospheric values. Trajectories and radiance simulations confirm that the H₂O, SO₂, and HCl enhancements were injected by the eruption. In comparison with those from previous eruptions, the SO₂ and HCl mass injections were unexceptional, although they reached higher altitudes. In contrast, the H₂O injection was unprecedented in both magnitude (far exceeding any previous values in the 17-year MLS record) and altitude (penetrating into the mesosphere). We estimate the mass of H₂O injected into the stratosphere to be 146 ± 5 Tg, or ∼10% of the stratospheric burden. It may take several years for the H₂O plume to dissipate. This eruption could impact climate not through surface cooling due to sulfate aerosols, but rather through surface warming due to the radiative forcing from the excess stratospheric H₂O.

The Hunga Tonga-Hunga Ha'apai Hydration of the Stratosphere

Following the 15 January 2022 Hunga Tonga-Hunga Ha'apai eruption, several trace gases measured by the Aura Microwave Limb Sounder (MLS) displayed anomalous stratospheric values. Trajectories and radiance simulations confirm that the H₂O, SO₂, and HCl enhancements were injected by the eruption. In comparison with those from previous eruptions, the SO₂ and HCl mass injections were unexceptional, although they reached higher altitudes. In contrast, the H₂O injection was unprecedented in both magnitude (far exceeding any previous values in the 17-year MLS record) and altitude (penetrating into the mesosphere). We estimate the mass of H₂O injected into the stratosphere to be 146 ± 5 Tg, or ∼10% of the stratospheric burden. It may take several years for the H₂O plume to dissipate. This eruption could impact climate not through surface cooling due to sulfate aerosols, but rather through surface warming due to the radiative forcing from the excess stratospheric H₂O.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

The Hunga Tonga-Hunga Ha'apai Hydration of the Stratosphere

Following the 15 January 2022 Hunga Tonga-Hunga Ha'apai eruption, several trace gases measured by the Aura Microwave Limb Sounder (MLS) displayed anomalous stratospheric values. Trajectories and radiance simulations confirm that the H₂O, SO₂, and HCl enhancements were injected by the eruption. In comparison with those from previous eruptions, the SO₂ and HCl mass injections were unexceptional, although they reached higher altitudes. In contrast, the H₂O injection was unprecedented in both magnitude (far exceeding any previous values in the 17-year MLS record) and altitude (penetrating into the mesosphere). We estimate the mass of H₂O injected into the stratosphere to be 146 ± 5 Tg, or ∼10% of the stratospheric burden. It may take several years for the H₂O plume to dissipate. This eruption could impact climate not through surface cooling due to sulfate aerosols, but rather through surface warming due to the radiative forcing from the excess stratospheric H₂O.

Technology implementation in care practices for community-dwelling older adults with mild cognitive decline: Perspectives of professional caregivers in Quebec and Brussels

OBJECTIVE

As worldwide population aging is accelerating, innovative technologies are being developed to support independent living among community-dwelling older adults with mild cognitive decline. However, the successful implementation of these interventions is often challenging. Until now, literature on implementation issues related to the specific context of older adults with mild cognitive decline is lacking and the few studies available do not focus specifically on the perspective of professional caregivers. Yet the perspective of these caregivers is important as they can be considered a key facilitator for technology implementation among this population. Therefore, this study was the first to examine technology implementation among community-dwelling older adults with mild cognitive decline from the broader perspective of professional caregivers.

METHODS

In this qualitative study, two focus groups consisting of a heterogeneous pool of professional caregivers were conducted: one in Quebec (Canada, n = 6) and one in Brussels (Belgium, n = 8). Braun and Clarke' method for thematic analysis, guided by a qualitative descriptive approach was applied to inductively identify themes from the data.

RESULTS

We identified factors influencing technology implementation in older adults with mild cognitive decline on three levels: an individual level (e.g., characteristics of older adults with mild cognitive decline and professional caregivers' attitude), an organizational level (e.g., lack of training among professional caregivers) and a level referring to the broader context (e.g., ethical considerations).

CONCLUSIONS

This study contributes to the research gap in knowledge on the needs of professional caregivers to facilitate technology implementation among the population of older adults with cognitive decline. Future directions for research, practice, and policy are given, more specifically to improve knowledge among caregivers and on the development of decision support to retrieve safe and effective technologies that suit patient-centered care.

Socio-Economic Impacts of COVID-19 on Working Mothers in France

Beyond its devastating consequences for public health, the COVID-19 pandemic had a major impact on gender inequalities, labour markets and families. Compared to many European countries, the French approach to lockdown was among the more stringent, although the measures taken by the French government to support employment, to some extent, mitigated the worst effects of the crisis on families. This article analyses the implications of COVID lockdown restrictions on gender equality and well-being for couples with children in France. The study adopted a multidimensional approach to gender inequalities associated with paid work and various dimensions of living conditions, involving gender-differentiated access to personal work spaces in the home, personal leisure time outside the home, and local support networks during the first phase of lockdown (March-June 2020). Drawing on data from the COCONEL survey, carried out by the Institut national d'études démographiques on a quota sample of the French adult population in April/May 2020, the authors controlled for variables including socio-economic status, age, family structure and place of residence. The survey data were complemented by a longitudinal set of in-depth interviews enabling the research team to capture the differential effects of the pandemic within couples. The main findings indicate that, despite the frequency of dual-employment arrangements for heterosexual couple households with dependent children, French mothers were nevertheless more likely to reduce their working time and/or withdraw from the labour market. Within the households surveyed, mothers were less likely than fathers to leave the home during the day, particularly for personal leisure activities. The presence of children in households increased gender inequality in both employment and living conditions across all socio-economic categories. In conclusion, the authors consider whether the pandemic might have a long-term impact on gender norms and inequalities within families, and how the findings about changes in gender inequalities could be used to inform public policy development.

Bullous haemorrhagic dermatitis induced by heparins and other anticoagulants: 94 cases from French pharmacovigilance centres and a literature review

BACKGROUND

Bullous haemorrhagic dermatitis (BHD) is an uncommon and highly particular side effect of various forms of heparins.

METHODS

To better characterise the disease, we collected all cases from French Pharmacovigilance centres recorded over a 20-year period (37 cases) and performed a Medline literature search up to June 2020 (57 cases).

RESULTS

In all, 94 patients were identified (male/female ratio: 2.2) of mean age 73.5±12.1 years (31-94). Patients were treated with enoxaparin (n=66), unfractionated heparin (n=11), fondaparinux (n=10), tinzaparin (n=4), bemiparin (n=1), reviparin (n=1), dalteparin (n=1), and 4 with other anticoagulants: warfarin (n=3) and rivaroxaban (n=1). All cases presented with 1 to more than 100 haemorrhagic vesicles and bullae, distant from the injection sites, located mainly on the lower (75%) or upper limbs (69%). The lesions were asymptomatic, except in 5 patients who had pruritic or painful lesions. The interval between treatment initiation and BHD ranged from 6 hours to 30 days (mean: 8.4±7 days). Biopsy (n=53) showed intraepidermal or subcorneal cavity with red cells (n=39) or junctional blisters (n=10), with eosinophilic infiltrate only rarely. Direct immuno-fluorescence was negative in 19/20 cases and indirect immunofluorescence was negative in 8/8. The outcome was favourable in all cases, including in 12 patients for whom heparin was maintained. A 93-year-old patient died of compressive haematomas unrelated to BHD. We found 5 cases similar to BHD due to other anticoagulants.

DISCUSSION

This is the largest comprehensive series of this adverse effect due to heparins or, more rarely, to other anticoagulants. Dermatologists must be aware of BHD, since this benign side effect does not necessarily require interruption of treatment. It is rare, considering the large-scale prescription of heparins, and occurs mainly in male patients aged over 70. Although the presentation is highly typical, the physiopathology is difficult to understand, as coagulation parameters are usually normal. Aging, skin fragility or mechanical factors might play a role.

Troponin measurement for risk stratification after cytoreductive surgery

Several studies have raised interest in the use of postoperative troponin levels to stratify risk of postoperative morbidity and mortality. In this study, postoperative troponin concentration after cytoreductive surgery (with or without hyperthermic intraoperative intraperitoneal chemotherapy) was associated with severe postoperative complications, and enhanced the predictive capability of a multivariable model focusing on postoperative complications.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

Fetal cerebellar growth and Sylvian fissure maturation: international standards from Fetal Growth Longitudinal Study of INTERGROWTH-21st Project

OBJECTIVE

To construct international ultrasound-based standards for fetal cerebellar growth and Sylvian fissure maturation.

METHODS

Healthy, well nourished pregnant women, enrolled at < 14 weeks' gestation in the Fetal Growth Longitudinal Study (FGLS) of INTERGROWTH-21^st , an international multicenter, population-based project, underwent serial three-dimensional (3D) fetal ultrasound scans every 5 ± 1 weeks until delivery in study sites located in Brazil, India, Italy, Kenya and the UK. In the present analysis, only those fetuses that underwent developmental assessment at 2 years of age were included. We measured the transcerebellar diameter and assessed Sylvian fissure maturation using two-dimensional ultrasound images extracted from available 3D fetal head volumes. The appropriateness of pooling data from the five sites was assessed using variance component analysis and standardized site differences. For each Sylvian fissure maturation score (left or right side), mean gestational age and 95% CI were calculated. Transcerebellar diameter was modeled using fractional polynomial regression, and goodness of fit was assessed.

RESULTS

Of those children in the original FGLS cohort who had developmental assessment at 2 years of age, 1130 also had an available 3D ultrasound fetal head volume. The sociodemographic characteristics and pregnancy/perinatal outcomes of the study sample confirmed the health and low-risk status of the population studied. In addition, the fetuses had low morbidity and adequate growth and development at 2 years of age. In total, 3016 and 2359 individual volumes were available for transcerebellar-diameter and Sylvian-fissure analysis, respectively. Variance component analysis and standardized site differences showed that the five study populations were sufficiently similar on the basis of predefined criteria for the data to be pooled to produce international standards. A second-degree fractional polynomial provided the best fit for modeling transcerebellar diameter; we then estimated gestational-age-specific 3^rd , 50^th and 97^th smoothed centiles. Goodness-of-fit analysis comparing empirical centiles with smoothed centile curves showed good agreement. The Sylvian fissure increased in maturation with advancing gestation, with complete overlap of the mean gestational age and 95% CIs between the sexes for each development score. No differences in Sylvian fissure maturation between the right and left hemispheres were observed.

CONCLUSION

We present, for the first time, international standards for fetal cerebellar growth and Sylvian fissure maturation throughout pregnancy based on a healthy fetal population that exhibited adequate growth and development at 2 years of age. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Determination of the optimal dose of ephedrine in the treatment of arterial hypotension due to general anesthesia in neonates and infants below 6 months old: the ephedrine study protocol for a randomized, open-label, controlled, dose escalation trial

BACKGROUND

Arterial hypotension induced by general anesthesia is commonly identified as a risk factor of morbidity, especially neurological, after cardiac or noncardiac surgery in adults and children. Intraoperative hypotension is observed with sevoflurane anesthesia in children, in particular in neonates, infants younger than 6 months, and preterm babies. Ephedrine is commonly used to treat intraoperative hypotension. It is an attractive therapeutic, due to its dual action on receptors alpha and beta and its possible peripheral intravenous infusion. There are few data in the literature on the use of ephedrine in the context of pediatric anesthesia. The actual recommended dose of ephedrine (0.1 to 0.2 mg/Kg) frequently leads to a therapeutic failure in neonates and infants up to 6 months of age. The use of higher doses would probably lead to a better correction of hypotension in this population. The objective of our project is to determine the optimal dose of ephedrine for the treatment of hypotension after induction of general anesthesia with sevoflurane, in neonates and infants up to 6 months of age.

METHODS

The ephedrine study is a prospective, randomized, open-label, controlled, dose-escalation trial. The dose escalation consists of 6 successive cohorts of 20 subjects. The doses studied are 0.6, 0.8, 1, 1.2, and 1.4 mg/kg. The dose chosen as the reference is 0.1 mg/kg, the actual recommended dose. Neonates and infants younger than 6 months, males and females, including preterm babies who undergo a surgery with general anesthesia inducted with sevoflurane were eligible. Parents of the subject were informed. Then, the subjects were randomized if presenting a decrease in mean blood pressure superior to 20% of their initial mean blood pressure (before induction of anesthesia), despite a vascular filling with sodium chloride 0.9%. The primary outcome is the success of the therapy defined as an mBP superior to 80% of the baseline mBP (prior to anesthesia) within 10 min post ephedrine administration. The subjects were followed-up for 3 days postanesthesia.

DISCUSSION

This study is the first randomized, controlled trial intending to determine the optimal dose of ephedrine to treat hypotension in neonates and infants below 6 months old.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02384876 . Registered on March 2015.

International standards for fetal brain structures based on serial ultrasound measurements from Fetal Growth Longitudinal Study of INTERGROWTH-21st Project

OBJECTIVE

To create prescriptive growth standards for five fetal brain structures, measured using ultrasound, in healthy, well-nourished women at low risk of impaired fetal growth and poor perinatal outcome, taking part in the Fetal Growth Longitudinal Study (FGLS) of the INTERGROWTH-21^st Project.

METHODS

This was a complementary analysis of a large, population-based, multicenter, longitudinal study. The sample analyzed was selected randomly from the overall FGLS population, ensuring an equal distribution among the eight diverse participating sites and of three-dimensional (3D) ultrasound volumes across pregnancy (range: 15-36 weeks' gestation). We measured, in planes reconstructed from 3D ultrasound volumes of the fetal head at different timepoints in pregnancy, the size of the parieto-occipital fissure (POF), Sylvian fissure (SF), anterior horn of the lateral ventricle, atrium of the posterior horn of the lateral ventricle (PV) and cisterna magna (CM). Fractional polynomials were used to construct the standards. Growth and development of the infants were assessed at 1 and 2 years of age to confirm their adequacy for constructing international standards.

RESULTS

From the entire FGLS cohort of 4321 women, 451 (10.4%) were selected at random. After exclusions, 3D ultrasound volumes from 442 fetuses born without a congenital malformation were used to create the charts. The fetal brain structures of interest were identified in 90% of cases. All structures, except the PV, showed increasing size with gestational age, and the size of the POF, SF, PV and CM showed increasing variability. The 3^rd , 5^th , 50^th , 95^th and 97^th smoothed centiles are presented. The 5^th centiles for the POF and SF were 3.1 mm and 4.7 mm at 22 weeks' gestation and 4.6 mm and 9.9 mm at 32 weeks, respectively. The 95^th centiles for the PV and CM were 8.5 mm and 7.5 mm at 22 weeks and 8.6 mm and 9.5 mm at 32 weeks, respectively.

CONCLUSIONS

We have produced prescriptive size standards for fetal brain structures based on prospectively enrolled pregnancies at low risk of abnormal outcome. We recommend these as international standards for the assessment of measurements obtained using ultrasound from fetal brain structures. © 2020 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Effectiveness of a short functional restoration program for patients with chronic low back pain: A cohort study of 193 patients

OBJECTIVE

Functional restoration programs (FRPs) are integrative programs to improve function in chronic low back pain (cLBP). They are costly and time-consuming. The aim was to assess the effectiveness of a condensed FRP (CFRP) for patients with cLBP in professional activity.

METHODS

Longitudinal 3 months study of patients with cLBP in one tertiary care hospital, participating in a CFRP over 4 separate days. The primary outcome was the Oswestry Disability Index (ODI). Secondary outcomes included pain, quality of life (EQ5D), patient acceptable symptom state, presenteeism, absenteeism and psychological distress. Outcomes were compared using paired sample Student's t-test or Chi² between baseline and last follow-up. Logistic regression was used to identify factors associated with better response (improvement of ODI higher than 12.8).

RESULTS

In all, 193 patients were analysed, mean age 44.6 (standard deviation (SD) 10.4) years, mean cLBP duration 9.0 (SD 8.8) years. A small improvement was observed for ODI (mean difference -5.9, 95% confidence interval: -7.6, -4.1), as well as most other outcomes. Multivariate analysis showed an association between ODI improvement and higher duration of low back pain (odds ratio for 5 years: 1.41 (1.06,1.88)) and lower baseline back strength (Sorensen, odds ratio for 1min: 0.54 [0.29,0.99]).

CONCLUSION

This CFRP showed small effect to improve function, pain and other quality of life, in cLBP. Four-day programs may be an interesting option in cLBP patients still in professional activity for whom a long 1-month FRP is difficultly manageable. Further studies with randomized controlled designs are needed to confirm the benefits.

C-16 Assessment of 9-Year-Old, Nonverbal Female with Spastic Cerebral Palsy & Seizure Disorder

Objective

Case serves to illuminate how complex medical/neurological/motor history can be assessed creatively/thoroughly while maintaining standardization in an effort to determine true abilities of young girl. Earlier evaluation suggested NVIQ scores in the 30th percentile, however more recent school testing suggested performance in 2nd percentile.

Method

Nine-year-old, Caucasian, right-handed female with diagnoses of spastic CP, recent seizures with LOC, GERD, assessing functioning/academic needs. Pt born 40-weeks gestation via c-section due to fetal heartbeat loss resulting in emergency CPR/NICU admission for six weeks. MRI suggests significant hypoxia-related prenatal damage to right frontal/temporal regions. Nerve/muscle development results in leftward preference permitting rightward movement. Pt is nonverbal, implanted gastrostomy tube, utilizes modified sign-language/augmentative, alternative communication device (AACD). Current behavioral concerns in multiple settings. Pt prescribed esomeprazole, baclofen, oxcarbazepine.

Results

Results suggest deficits in adaptive functioning, set-shifting, language. Sustaining gaze was difficult, with subsequent invalid scores on numerous measures. Even with incorrect responses, Pt understood TEACh tasks. Given tools (calculator) at her disposal, Pt scored in 30th percentile on Math Computation. Further, TONI-4 nonverbal index was stronger than school expectations (10th percentile). PTONI negatively impacted by motor deficits. AACD offered limited vocabulary – Pt appeared well-aware of missing words when they arose (small vs. thin). Pt demonstrated high frustration-tolerance and ability to joke with examiners.

Conclusions

Conclusions: Pt’s performance and motivation were highly impressive given circumstances. Even with limiting factors, standardized measures can be utilized with critical qualitative observations to acquire more representative test results, provide adequate recommendations for ongoing care/accommodations, thereby advocating for academic success and improving Pt well-being.

Long-Term Sheep Implantation of WIMAGINE®, a Wireless 64-Channel Electrocorticogram Recorder

This article deals with the long-term preclinical validation of WIMAGINE^® (Wireless Implantable Multi-channel Acquisition system for Generic Interface with Neurons), a 64-channel wireless implantable recorder that measures the electrical activity at the cortical surface (electrocorticography, ECoG). The WIMAGINE^® implant was designed for chronic wireless neuronal signal acquisition, to be used e.g., as an intracranial Brain–Computer Interface (BCI) for severely motor-impaired patients. Due to the size and shape of WIMAGINE^®, sheep appeared to be the best animal model on which to carry out long-term in vivo validation. The devices were implanted in two sheep for a follow-up period of 10 months, including idle state cortical recordings and Somato-Sensory Evoked Potential (SSEP) sessions. ECoG and SSEP demonstrated relatively stable behavior during the 10-month observation period. Information recorded from the SensoriMotor Cortex (SMC) showed an SSEP phase reversal, indicating the cortical site of the sensorimotor activity was retained after 10 months of contact. Based on weekly recordings of raw ECoG signals, the effective bandwidth was in the range of 230 Hz for both animals and remarkably stable over time, meaning preservation of the high frequency bands valuable for decoding of the brain activity using BCIs. The power spectral density (in dB/Hz), on a log scale, was of the order of 2.2, –4.5 and –18 for the frequency bands (10–40), (40–100), and (100–200) Hz, respectively. The outcome of this preclinical work is the first long-term in vivo validation of the WIMAGINE^® implant, highlighting its ability to record the brain electrical activity through the dura mater and to send wireless digitized data to the external base station. Apart from local adhesion of the dura to the skull, the neurosurgeon did not face any difficulty in the implantation of the WIMAGINE^® device and post-mortem analysis of the brain revealed no side effect related to the implantation. We also report on the reliability of the system; including the implantable device, the antennas module and the external base station.

Staging and normal table of postembryonic development of the clownfish (Amphiprion ocellaris)

Background

The clownfish Amphiprion ocellaris is one of the rare coral reef fish species that can be reared in aquaria. With relatively short embryonic and larval development, it could be used as a model species to study the impact of global changes such as temperature rise or anthropogenic threats (eg, pollution) on the postembryonic development at molecular and endocrinological levels. Establishing a developmental table allows us to standardize sampling for the scientific community willing to conduct experiments on this species on different areas: ecology, evolution, and developmental biology.

Results

Here, we describe the postembryonic developmental stages for the clownfish A. ocellaris from hatching to juvenile stages (30 days posthatching). We quantitatively followed the postembryonic growth and described qualitative traits: head, paired and unpaired fins, notochord flexion, and pigmentation changes. The occurrence of these changes over time allowed us to define seven stages, for which we provide precise descriptions.

Conclusions

Our work gives an easy system to determine A. ocellaris postembryonic stages allowing, thus, to develop this species as a model species for coral reef fishes. In light of global warming, the access to the full postembryonic development stages of coral reef fish is important to determine stressors that can affect such processes.

Seven developmental stages have been identified to describe the larval development of the clownfish Amphiprion ocellaris.

Clownfish larvae undergo two distinct developmental growth phases that correspond to growth and metamorphosis.

A dichotomous key determination has been created to assist users in identifying the various developmental stages.

Comparison of Three Real-Time PCR Assays for the Detection of PIK3CA Somatic Mutations in Formalin-Fixed Paraffin Embedded Tissues of Patients with Breast Carcinomas

Breast cancer is the leading cause of cancer-related death in women worldwide. Mutations of the PIK3CA gene are found in approximately 25% of breast carcinomas and are reported as activators of the PI3K/AKT/mTOR pathway. This study aims to compare three assays for the somatic mutation detection of PIK3CA gene in FFPE tissues of patients with breast cancer. We compared Cobas® PIK3CA Mutation Test (Roche Diagnostics, Meylan, France), PCR amplification-refractory mutation system Scorpions® (ARMS) and High-Resolution Melting PCR assay (HRM) for the detection of PIK3CA mutations. Discrepant samples were assessed using Next Generation Sequencing (NGS). 46 FFPE breast carcinomas samples of patients treated for breast cancer have been assessed for PIK3CA mutations using the three PCR assays. Among the 46 samples, 17 (37.8%), 13 (28.36%) and 19 (41.3%) had a PIK3CA mutation, with Cobas®, ARMS and HRM assays respectively. Three different mutations of PIK3CA have been detected for one sample. Calculated kappa were 0.95[0.86;1] between Cobas® and HRM, 0.75[0.55;0.95] between Cobas® and ARMS and 0.72[0.51;0.92] between HRM and ARMS. Five samples were found with discrepant results. Our study shows that the Cobas® assay is suitable for PIK3CA mutation assessment in patients with breast cancer. HRM assay is also suitable for PIK3CA mutation assessment but requires a mutation characterization with a specific assay.

Fish larval recruitment to reefs is a thyroid hormone-mediated metamorphosis sensitive to the pesticide chlorpyrifos

Larval recruitment, the transition of pelagic larvae into reef-associated juveniles, is a critical step for the resilience of marine fish populations but its molecular control is unknown. Here, we investigate whether thyroid-hormones (TH) and their receptors (TR) coordinate the larval recruitment of the coral-reef-fish Acanthurus triostegus. We demonstrate an increase of TH-levels and TR-expressions in pelagic-larvae, followed by a decrease in recruiting juveniles. We generalize these observations in four other coral reef-fish species. Treatments with TH or TR-antagonist, as well as relocation to the open-ocean, disturb A. triostegus larvae transformation and grazing activity. Likewise, chlorpyrifos, a pesticide often encountered in coral-reefs, impairs A. triostegus TH-levels, transformation, and grazing activity, hence diminishing this herbivore’s ability to control the spread of reef-algae. Larval recruitment therefore corresponds to a TH-controlled metamorphosis, sensitive to endocrine disruption. This provides a framework to understand how larval recruitment, critical to reef-ecosystems maintenance, is altered by anthropogenic stressors.

Many animals go through a larval phase before developing into an adult. This transformation is called metamorphosis, and it is regulated by hormones of the thyroid gland in vertebrates. For example, most fish found on coral reefs actually spend the first part of their life as free-swimming larvae out in the ocean. The larvae usually look very different from the juveniles and adults. When these fish become juveniles, the larvae undergo a range of physical and behavioral changes to prepare for their life on the reef. Yet, until now it was not known what hormones control metamorphosis in these fish.

To address this question, Holzer, Besson et al. studied the convict surgeonfish Acanthurus triostegus. This herbivorous coral-reef fish lives in the Indo-Pacific Ocean, and the results showed that thyroid hormones do indeed regulate the metamorphosis of its larvae. This includes changing how the larvae behave and how their adult features develop. Further, Holzer, Besson et al. found that this was also true for four other coral-reef fish, including the lagoon triggerfish and the raccoon butterflyfish. In A. triostegus, thyroid hormones controlled the changes that enabled the juveniles to efficiently graze on algae growing on the reef such as an elongated gut.

When the fish larvae were then exposed to a pesticide called chlorpyrifos, a well-known reef pollutant, their hormone production was disturbed. This in turn affected their grazing behavior and also their metamorphosis. These fish had shortened, underdeveloped guts and could not graze on algae as effectively.

Herbivorous fish such as A. triostegus play a major role in supporting coral reef ecosystems by reducing algal cover and therefore promoting coral recruitment. These new findings show that pollutants from human activities could disturb the metamorphosis of coral-reef fish and, as a consequence, their ability to maintain the reefs. A next step will be to test what other factors can disrupt the hormones in coral-reef fish and thus pose a threat for fish populations and the coral-reef ecosystem.

Paediatric injection medialisation laryngoplasty: Recent Great Ormond Street Hospital experience

INTRODUCTION

Unilateral vocal fold paresis may significantly impair the vocal quality and laryngeal competence of a child. Relatively little literature relates to injection medialisation laryngoplasty (IML) in children and previous reports have involved small numbers of heterogenous cases.

METHODS

A retrospective review was conducted of paediatric patients managed by our multidisciplinary specialist voice clinic undergoing IML for unilateral vocal fold paresis. Cases of bilateral paresis, those characterised by vocal fold fixation, and patients without formal pre and post-operative voice evaluation were excluded.

RESULTS

Eighteen IML procedures were performed in 12 children eligible for inclusion between 2005 and 2015. The average age at time of procedure was 12 years (range 9-15 years). Autologous fat was used in 5 procedures, succeeded by calcium hydroxylapatite (Radiesse^® Voice) from 2011 (n = 13). A significant improvement in median GRBAS score components was observed after calcium hydroxylapatite injection in terms of grade (p = 0.008), breathiness (p = 0.002) and aesthenia (p = 0.016). A pre- and post-procedural Voice Handicap Index was self-completed by 6 patients receiving calcium hydroxylapatite injection; the median change in score was an improvement of 19 points (interquartile range 36.5).

CONCLUSION

We describe the outcomes of a comparatively large paediatric series and have found IML using calcium hydroxylapatite to be a reliable technique associated with improved subjective outcome measures. Management of UVCP in the child is a challenge with particular investigative and interventional considerations. Further study supported by high quality subjective and, where possible, objective outcome measures, is required to better inform patient selection, timing of intervention and choice of injection material.

International estimated fetal weight standards of the INTERGROWTH-21st Project

OBJECTIVE

Estimated fetal weight (EFW) and fetal biometry are complementary measures used to screen for fetal growth disturbances. Our aim was to provide international EFW standards to complement the INTERGROWTH-21^st Fetal Growth Standards that are available for use worldwide.

METHODS

Women with an accurate gestational-age assessment, who were enrolled in the prospective, international, multicenter, population-based Fetal Growth Longitudinal Study (FGLS) and INTERBIO-21^st Fetal Study (FS), two components of the INTERGROWTH-21^st Project, had ultrasound scans every 5 weeks from 9-14 weeks' until 40 weeks' gestation. At each visit, measurements of fetal head circumference (HC), biparietal diameter, occipitofrontal diameter, abdominal circumference (AC) and femur length (FL) were obtained blindly by dedicated research sonographers using standardized methods and identical ultrasound machines. Birth weight was measured within 12 h of delivery by dedicated research anthropometrists using standardized methods and identical electronic scales. Live babies without any congenital abnormality, who were born within 14 days of the last ultrasound scan, were selected for inclusion. As most births occurred at around 40 weeks' gestation, we constructed a bootstrap model selection and estimation procedure based on resampling of the complete dataset under an approximately uniform distribution of birth weight, thus enriching the sample size at extremes of fetal sizes, to achieve consistent estimates across the full range of fetal weight. We constructed reference centiles using second-degree fractional polynomial models.

RESULTS

Of the overall population, 2404 babies were born within 14 days of the last ultrasound scan. Mean time between the last scan and birth was 7.7 (range, 0-14) days and was uniformly distributed. Birth weight was best estimated as a function of AC and HC (without FL) as log(EFW) = 5.084820 - 54.06633 × (AC/100)³  - 95.80076 × (AC/100)³  × log(AC/100) + 3.136370 × (HC/100), where EFW is in g and AC and HC are in cm. All other measures, gestational age, symphysis-fundus height, amniotic fluid indices and interactions between biometric measures and gestational age, were not retained in the selection process because they did not improve the prediction of EFW. Applying the formula to FGLS biometric data (n = 4231) enabled gestational age-specific EFW tables to be constructed. At term, the EFW centiles matched those of the INTERGROWTH-21^st Newborn Size Standards but, at < 37 weeks' gestation, the EFW centiles were, as expected, higher than those of babies born preterm. Comparing EFW cross-sectional values with the INTERGROWTH-21^st Preterm Postnatal Growth Standards confirmed that preterm postnatal growth is a different biological process from intrauterine growth.

CONCLUSIONS

We provide an assessment of EFW, as an adjunct to routine ultrasound biometry, from 22 to 40 weeks' gestation. However, we strongly encourage clinicians to evaluate fetal growth using separate biometric measures such as HC and AC, as well as EFW, to avoid the minimalist approach of focusing on a single value. © 2016 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Transcriptomic signatures shaped by cell proportions shed light on comparative developmental biology

Background

Comparative transcriptomics can answer many questions in developmental and evolutionary developmental biology. Most transcriptomic studies start by showing global patterns of variation in transcriptomes that differ between species or organs through developmental time. However, little is known about the kinds of expression differences that shape these patterns.

Results

We compared transcriptomes during the development of two morphologically distinct serial organs, the upper and lower first molars of the mouse. We found that these two types of teeth largely share the same gene expression dynamics but that three major transcriptomic signatures distinguish them, all of which are shaped by differences in the relative abundance of different cell types. First, lower/upper molar differences are maintained throughout morphogenesis and stem from differences in the relative abundance of mesenchyme and from constant differences in gene expression within tissues. Second, there are clear time-shift differences in the transcriptomes of the two molars related to cusp tissue abundance. Third, the transcriptomes differ most during early-mid crown morphogenesis, corresponding to exaggerated morphogenetic processes in the upper molar involving fewer mitotic cells but more migrating cells. From these findings, we formulate hypotheses about the mechanisms enabling the two molars to reach different phenotypes. We also successfully applied our approach to forelimb and hindlimb development.

Conclusions

Gene expression in a complex tissue reflects not only transcriptional regulation but also abundance of different cell types. This knowledge provides valuable insights into the cellular processes underpinning differences in organ development. Our approach should be applicable to most comparative developmental contexts.

Electronic supplementary material

The online version of this article (doi:10.1186/s13059-017-1157-7) contains supplementary material, which is available to authorized users.

Obstructive jaundice: a clinical review for the UK armed forces

Obstructive jaundice is a clinical condition that indicates the possibility of a significant underlying disease process. This clinical review considers the pathophysiology, investigation and management of patients with obstructive jaundice and considers the particular challenges that medical personnel may face when deployed away from the United Kingdom (UK). It aims to give guidance with regard to the short- and long-term investigation and management of such patients.

The antepartum stillbirth syndrome: risk factors and pregnancy conditions identified from the INTERGROWTH-21st Project

OBJECTIVES

To identify risk factors for antepartum stillbirth, including fetal growth restriction, among women with well-dated pregnancies and access to antenatal care.

DESIGN

Population-based, prospective, observational study.

SETTING

Eight international urban populations.

POPULATION

Pregnant women and their babies enrolled in the Newborn Cross-Sectional Study of the INTERGROWTH-21^st Project.

METHODS

Cox proportional hazard models were used to compare risks among antepartum stillborn and liveborn babies.

MAIN OUTCOME MEASURES

Antepartum stillbirth was defined as any fetal death after 16 weeks' gestation before the onset of labour.

RESULTS

Of 60 121 babies, 553 were stillborn (9.2 per 1000 births), of which 445 were antepartum deaths (7.4 per 1000 births). After adjustment for site, risk factors were low socio-economic status, hazard ratio (HR): 1.6 (95% CI, 1.2-2.1); single marital status, HR 2.0 (95% CI, 1.4-2.8); age ≥40 years, HR 2.2 (95% CI, 1.4-3.7); essential hypertension, HR 4.0 (95% CI, 2.7-5.9); HIV/AIDS, HR 4.3 (95% CI, 2.0-9.1); pre-eclampsia, HR 1.6 (95% CI, 1.1-3.8); multiple pregnancy, HR 3.3 (95% CI, 2.0-5.6); and antepartum haemorrhage, HR 3.3 (95% CI, 2.5-4.5). Birth weight <3rd centile was associated with antepartum stillbirth [HR, 4.6 (95% CI, 3.4-6.2)]. The greatest risk was seen in babies not suspected to have been growth restricted antenatally, with an HR of 5.0 (95% CI, 3.6-7.0). The population-attributable risk of antepartum death associated with small-for-gestational-age neonates diagnosed at birth was 11%.

CONCLUSIONS

Antepartum stillbirth is a complex syndrome associated with several risk factors. Although small babies are at higher risk, current growth restriction detection strategies only modestly reduced the rate of stillbirth.

TWEETABLE ABSTRACT

International stillbirth study finds individual risks poor predictors of death but combinations promising.

Ultrasound-based gestational-age estimation in late pregnancy

OBJECTIVE

Accurate gestational-age (GA) estimation, preferably by ultrasound measurement of fetal crown-rump length before 14 weeks' gestation, is an important component of high-quality antenatal care. The objective of this study was to determine how GA can best be estimated by fetal ultrasound for women who present for the first time late in pregnancy with uncertain or unknown menstrual dates.

METHODS

INTERGROWTH-21^st was a large, prospective, multicenter, population-based project performed in eight geographically defined urban populations. One of its principal components, the Fetal Growth Longitudinal Study, aimed to develop international fetal growth standards. Each participant had their certain menstrual dates confirmed by first-trimester ultrasound examination. Fetal head circumference (HC), biparietal diameter (BPD), occipitofrontal diameter (OFD), abdominal circumference (AC) and femur length (FL) were measured every 5 weeks from 14 weeks' gestation until delivery. For each participant, a single, randomly selected ultrasound examination was used to explore all candidate biometric variables and permutations to build models to predict GA. Regression equations were ranked based upon minimization of the mean prediction error, goodness of fit and model complexity. An automated machine learning algorithm, the Genetic Algorithm, was adapted to evaluate > 64 000 potential polynomial equations as predictors.

RESULTS

Of the 4607 eligible women, 4321 (94%) had a pregnancy without major complications and delivered a live singleton without congenital malformations. After other exclusions (missing measurements in GA window and outliers), the final sample comprised 4229 women. Two skeletal measures, HC and FL, produced the best GA prediction, given by the equation log_e (GA) = 0.03243 × (log_e (HC))² + 0.001644 × FL × log_e (HC) + 3.813. When FL was not available, the best equation based on HC alone was log_e (GA) = 0.05970 × (log_e (HC))² + 0.000000006409 × (HC)³ + 3.3258. The estimated uncertainty of GA prediction (half width 95% interval) was 6-7 days at 14 weeks' gestation, 12-14 days at 26 weeks' gestation and > 14 days in the third trimester. The addition of FL to the HC model led to improved prediction intervals compared with using HC alone, but no further improvement in prediction was afforded by adding AC, BPD or OFD. Equations that included other measurements (BPD, OFD and AC) did not perform better.

CONCLUSIONS

Among women initiating antenatal care late in pregnancy, a single set of ultrasound measurements combining HC and FL in the second trimester can be used to estimate GA with reasonable accuracy. We recommend this tool for underserved populations but considerable efforts should be implemented to improve early initiation of antenatal care worldwide. © 2016 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.