Socioeconomic differences in perinatal health outcomes: perinatal health surveillance through a health-equity prism

Background

Socioeconomic status (SES) is strongly associated with perinatal health outcomes, perpetuating intergenerational health inequalities. Our aim was to assess the utility of population data in Europe to monitor social inequalities in key perinatal health indicators.

Methods

Using the PHIRI federated analysis protocol to aggregate routine birth data from across Europe, we collected data on selected perinatal health indicators by SES from 2015 to 2020. Mothers’ education level (primary/lower secondary; upper secondary; postsecondary) was the preferred SES indicator; if unavailable, parents’ occupation or area-based deprivation scores were provided. The International Standard Classification of Occupations was used to group parents’ occupations into 4 categories, while area-based deprivation scores were measured in quintiles. For each country, we calculated risk ratios (RR) for preterm birth, stillbirth, neonatal death and caesarean delivery (CD) comparing the most with the least disadvantaged group

Results

17 countries provided data on maternal education, 5 on area-based deprivation, 1 on parents’ occupation and 2 could not provide data. For preterm birth, stillbirth and neonatal death, lower SES was associated with worse outcomes with most RR between lowest and highest groups in the range of 1.5 to 3.0. In contrast, in some countries, such as Croatia, Latvia, Lithuania and Spain, CD rates were higher for socially advantaged groups whereas the gradient was reversed in others (Denmark, Luxembourg, the Netherlands and Italy).

Conclusions

European countries can provide perinatal health indicators by SES, revealing marked socioeconomic inequalities in perinatal health. The differing SES gradient between countries for CD raise questions about care organization and clinical practice. Further exploration of the harmonization of differing SES measure across countries is required, while countries that do not monitor SES data should aim to improve existing systems.

Comparison of next-generation portable pollution monitors to measure exposure to PM2.5 from household air pollution in Puno, Peru

Assessment of personal exposure to PM_2.5 is critical for understanding intervention effectiveness and exposure-response relationships in household air pollution studies. In this pilot study, we compared PM_2.5 concentrations obtained from two next-generation personal exposure monitors (the Enhanced Children MicroPEM or ECM; and the Ultrasonic Personal Air Sampler or UPAS) to those obtained with a traditional Triplex Cyclone and SKC Air Pump (a gravimetric cyclone/pump sampler). We co-located cyclone/pumps with an ECM and UPAS to obtain 24-hour kitchen concentrations and personal exposure measurements. We measured Spearmen correlations and evaluated agreement using the Bland-Altman method. We obtained 215 filters from 72 ECM and 71 UPAS co-locations. Overall, the ECM and the UPAS had similar correlation (ECM ρ = 0.91 vs UPAS ρ = 0.88) and agreement (ECM mean difference of 121.7 µg/m³ vs UPAS mean difference of 93.9 µg/m³ ) with overlapping confidence intervals when compared against the cyclone/pump. When adjusted for the limit of detection, agreement between the devices and the cyclone/pump was also similar for all samples (ECM mean difference of 68.8 µg/m³ vs UPAS mean difference of 65.4 µg/m³ ) and personal exposure samples (ECM mean difference of -3.8 µg/m³ vs UPAS mean difference of -12.9 µg/m³ ). Both the ECM and UPAS produced comparable measurements when compared against a cyclone/pump setup.

[Hepatic portal venous gas: surgery or not surgery?]

Finding hepatic portal venous gas with pneumatosis intestinalis on computed tomography (CT) represents diagnostic and therapeutic challenge. The intestinal necrosis, particularly associated with acute mesenteric ischemia, is the very first hypothesis to assess, with the underlying question of an urgent surgery. However, knowing the non-surgical causes that have been identified in the last decade seems necessary to better assess the risk-benefit ratio of emergency surgery. Among these causes, we report the case of the acute colonic pseudo-obstruction, also known as Ogilvie's syndrome, whose first line treatment is medical.

Emergi-paths and stroke teams: an emergency department approach to acute ischemic stroke

In patients with early acute ischemic stroke (AIS), studies have shown improved recovery rates when thrombolytic therapy is appropriately initiated. However, in clinical practice, there are several barriers to rapid patient evaluation and drug administration. To facilitate the management of this population, an AIS clinical pathway, Emergi-path, was developed. Initiated at the time of the patients' arrival to the emergency department, Emergi-path provides a step-by-step guide for early care of AIS patients. A citywide stroke team plays an integral role in this process by responding to stroke codes. Implementation of an AIS pathway and activation of an organized team of stroke specialists can facilitate rapid evaluation and treatment of this high-risk population.

Zinc-responsive dermatosis in a red wolf (canis rufus)

An 18-mo-old male red wolf (Canis rufus) presented with footpad hyperkeratosis, suppurative paronychia, distal limb pyoderma, and peripheral lymphadenopathy. Diet for the previous 11 mo consisted of a mixture of two commercially prepared dog foods with a mineral supplement containing primarily calcium. Culture of the draining tracts on the distal limbs yielded a mixed population of opportunistic bacteria. Histopathologic findings were consistent with a diagnosis of zinc deficiency. Medical therapy consisted of 15 mg/kg amoxicillin p.o. b.i.d. and 10 mg/kg zinc sulfate p.o. s.i.d. Calcium supplementation was discontinued. Clinical signs resolved by 10 wk after the initiation of treatment.

Open label tissue plasminogen activator for stroke: The Oregon experience

BACKGROUND

Tissue plasminogen activator (t-PA) is the first effective treatment for stroke. This study sought to explore the outcome of patients treated with t-PA in the community after approval of its use in the treatment of stroke in June, 1996.

METHODS

All patients with acute stroke within the 6-hospital Oregon Stroke Center network were screened for potential t-PA treatment. Baseline and 24-hour outcome assessments were performed with the use of the National Institutes of Health Stroke Scale (NIHSS) and computed tomography (CT); 3-month outcome was evaluated by using the Modified Rankin scale.

RESULTS

Thirty-three patients who met the criteria for t-PA therapy were treated within 3 hours of symptom onset. All but 2 strokes were in the anterior circulation; 48.5% were cardioembolic. The NIHSS scores at 24 hours after administration of t-PA (mean, 14.7) showed modest gains from baseline NIHSS scores (mean, 16.6). Twelve patients (36%) had minimal or no deficits at 3 months. Three patients (9%), all of whom had baseline NIHSS scores of 20 or more, had symptomatic intracranial hemorrhages, 2 of which were fatal (6%).

CONCLUSION

This study shows the feasibility of treating acute stroke with t-PA in the community. The percentage of fully recovered patients at 3 months mirrored those in the National Institute of Neurologic Disorders and Stroke (NINDS) trial.

A clinical trial of retroviral-mediated transfer of a rev-responsive element decoy gene into CD34(+) cells from the bone marrow of human immunodeficiency virus-1-infected children

Genetic modification of hematopoietic stem cells with genes that inhibit replication of human immunodeficiency virus-1 (HIV-1) could lead to development of T lymphocytes and monocytic cells resistant to HIV-1 infection after transplantation. We performed a clinical trial to evaluate the safety and feasibility of this procedure, using bone marrow from four HIV-1-infected pediatric subjects (ages 8 to 17 years). We obtained bone marrow, isolated CD34(+) cells, performed in vitro transduction with a retroviral vector carrying a rev-responsive element (RRE) decoy gene, and reinfused the cells into these subjects with no evidence of adverse effects. The levels of gene-containing leukocytes in peripheral blood samples in the 1 year after gene transfer/cell infusion have been extremely low. These observations support the potential of performing gene therapy for HIV-1 using hematopoietic cells, but emphasize the need for improved gene transfer techniques.

Infection of human marrow stroma by human immunodeficiency virus-1 (HIV-1) is both required and sufficient for HIV-1-induced hematopoietic suppression in vitro: demonstration by gene modification of primary human stroma

Patients with human immunodeficiency virus-1 (HIV-1) infection often present with bone marrow (BM) failure that may affect all hematopoietic lineages. It is presently unclear whether this failure reflects a direct viral impairment of the CD34+ hematopoietic progenitor cells or whether the virus affects the BM microenvironment. To study the effects of HIV-1 on the BM microenvironment, we examined the stromal cell monolayers in long-term BM culture (LTBMC), which are the in vitro equivalent of the hematopoietic microenvironment. We assessed the hematopoietic support function (HSF) of human stromal layers by determining the cellular proliferation and colony-forming ability of hematopoietic progenitors from BM cells grown on the stromal layers. We show that the HSF is reduced by in vitro infection of the human stromal cell layer by a monocytotropic isolate of HIV-1 (JR-FL). There is no loss of HSF when the stromal cell layer is resistant to HIV-1 replication, either using murine stromal cell layers that are innately resistant to HIV-1 infection or using human stromal cells genetically modified to express a gene that inhibits HIV-1 replication (an RRE decoy). Decreased HSF was seen using either human or murine hematopoietic cells, if the stromal cells were human cells that were susceptible to HIV-1 infection. These in vitro studies implicate HIV-1 replication in the stroma as the essential component causing decreased hematopoietic cell production in HIV-1 infection.

Inhibition of human immunodeficiency virus-1 (HIV-1) replication after transduction of granulocyte colony-stimulating factor-mobilized CD34+ cells from HIV-1-infected donors using retroviral vectors containing anti-HIV-1 genes

Transfer of "anti-HIV-1 genes" into hematopoietic stem cells of human immunodeficiency virus-1 (HIV-1)-infected individuals may be a potent therapeutic approach to render mature cells arising from transduced stem cells resistant to the destructive events associated with HIV-1 infection. To determine the feasibility of gene therapy for acquired immunodeficiency syndrome in individuals already infected with HIV-1, granulocyte colony-stimulating factor mobilized peripheral blood CD34+ cells were isolated from HIV-1-infected individuals and transduced with retroviral vectors containing three different anti-HIV-1-genes: the Rev binding domain of the Rev Responsive Element (RRE decoy) (L-RRE-neo), a double hammerhead ribozyme vector targeted to cleave the tat and rev transcripts (L-TR/TAT-neo), and the trans-dominant mutant of rev (M10) (L-M10-SN). As a control, a vector mediating only neomycin resistance (LN) was used. After 3 days of transduction on allogeneic stroma in the presence of stem cell factor, interleukin-6 (IL-6), and IL-3, the cultures were G418-selected, and then challenged with HIV-1(JR-FL) and a primary HIV-1 isolate. Compared with the control cultures, the L-RRE-neo-, L-TR/TAT-neo-, and L-M10-SN-transduced cultures displayed up to 1,000-fold inhibition of HIV-1 replication after challenge with HIV-1(JR-FL) and the primary HIV-1 isolate. Growth of the hematopoietic cells in long-term bone marrow culture was not perturbed by the presence of any of the anti-HIV-1 genes. This study shows that anti-HIV-1 genes can be introduced into CD34+ cells from individuals already infected with HIV-1, and strongly inhibit HIV-1 replication in primary monocytes derived from the CD34+ progenitors.

Suitability of bone marrow from HIV-1-infected donors for retrovirus-mediated gene transfer

Bone marrow samples from 21 human immunodeficiency virus type 1 (HIV-1)-infected subjects were evaluated for their suitability for retrovirus-mediated gene transduction with anti-HIV-1 genes. The percentages of CD34+ cells that could be isolated from the mononuclear fraction of bone marrow samples were determined. Fifteen of the 21 marrow samples had normal percentages of CD34+ cells isolated by immunomagnetic methods. All seven donors with CD4 counts > 100/mm3 had normal percentages of CD34+ cells; of 14 patients with low CD4 cell counts (< 100/mm3), 5 had reduced and 9 had normal percentages of CD34+ cells. Samples of the marrow were plated in a methylcellulose colony-forming unit (CFU) assay to determine the clonogenic capacity of the progenitor cells. Overall, the marrow samples from HIV-infected donors showed a 44% reduction in CFU derived from the mononuclear cell fraction and a 75% reduction in CFU derived from the isolated CD34+ cell fraction, when compared to marrow samples from uninfected donors. Isolated CD3+ cells were transduced with retroviral vectors containing various anti-HIV-1 genes to determine their susceptibility to gene transfer. Transduction of the clonogenic CD34+ cells by retroviral vectors did not differ among marrow samples from 13 HIV-1+ donors and 9 uninfected donors. Long-term bone marrow cultures established from the transduced CD34+ cells demonstrated equivalent survival of clonogenic progenitor cells from both HIV-1-infected and uninfected marrows. Toxicity from expression of the anti-HIV-1 genes was not observed; the percentages of clonogenic progenitor cells that survived in cultures transduced by vectors carrying anti-HIV-1 genes were similar to those transduced by the control LN vectors. Stromal cells cultured from marrow samples from HIV-1-infected donors showed similar growth kinetics, hematopoietic support function, and enhancement of retrovirus-mediated transduction of CD34+ cells as seen with stromal cells cultured from uninfected marrow donors. Semi-quantitative polymerase chain reaction (PCR) was performed before and after ex vivo transduction to determine the frequency of HIV-1-containing cells in the CD34+ cell preparations. Although HIV-1+ cells were present at low levels in the mononuclear cell fractions of some of the marrow samples, the CD34+ cell preparation from only one marrow sample contained detectable HIV-1 positive cells (< 1 positive cell/100,000 by PCR) prior to transduction. None of the CD34+ cell preparations contained detectable HIV-1 after transduction. These studies demonstrate that HIV-1-infected patients are candidates for retrovirus-mediated transduction of anti-HIV-1 genes in bone marrow gene therapy clinical trials.

Transduction of human CD34+ hematopoietic progenitor cells by a retroviral vector expressing an RRE decoy inhibits human immunodeficiency virus type 1 replication in myelomonocytic cells produced in long-term culture

Genetic modification of hematopoietic stem cells with a synthetic "anti-human immunodeficiency virus type 1 (HIV-1) gene" which inhibits replication of HIV-1 may allow production of mature lymphoid and monocytic cells resistant to HIV-1 growth after autologous transplantation. Because productive HIV-1 replication requires binding of the Rev protein to the Rev-responsive element (RRE) within the viral transcripts for the HIV-1 structural proteins, anti-HIV-1 gene products which interfere with Rev-RRE interactions may inhibit HIV-1 replication. One such strategy involves overexpression of the RRE sequences in transcripts derived from retroviral vectors to act as decoys to sequester Rev protein and prevent its binding to the RRE element in HIV-1 transcripts. We developed an in vitro model to test the efficacy of this gene therapy approach in primary human hematopoietic cells. Human CD34+ hematopoietic progenitor cells from normal bone marrow or umbilical cord blood were transduced with retroviral vectors carrying RRE decoy sequences as part of a long terminal repeat-directed transcript expressing the neo gene (L-RRE-neo) or with a control vector expressing only the neo gene (LN). The transduced progenitors were allowed to differentiate into mature myelomonocytic cells which were able to support vigorous growth of the monocytotropic isolate of HIV-1, JR-FL. HIV-1 replication was measured in unselected cell populations and following G418 selection to obtain uniformly transduced cell populations. Inhibition of HIV-1 replication in the unselected cell cultures was between 50.2 and 76.7% and was highly effective (99.4 to 99.9%) in the G418-selected cultures. Progenitors transduced by either the L-RRE-neo vector or the control LN vector were identical with respect to hematopoietic growth and differentiation. These findings demonstrate the ability of an RRE decoy strategy to inhibit HIV-1 replication in primary human myelomonocytic cells after transduction of CD34+ progenitor cells, without adverse effects on hematopoietic cell function.