Fully automated planning for anatomical fetal brain MRI on 0.55T

PURPOSE

Widening the availability of fetal MRI with fully automatic real-time planning of radiological brain planes on 0.55T MRI.

METHODS

Deep learning-based detection of key brain landmarks on a whole-uterus echo planar imaging scan enables the subsequent fully automatic planning of the radiological single-shot Turbo Spin Echo acquisitions. The landmark detection pipeline was trained on over 120 datasets from varying field strength, echo times, and resolutions and quantitatively evaluated. The entire automatic planning solution was tested prospectively in nine fetal subjects between 20 and 37 weeks. A comprehensive evaluation of all steps, the distance between manual and automatic landmarks, the planning quality, and the resulting image quality was conducted.

RESULTS

Prospective automatic planning was performed in real-time without latency in all subjects. The landmark detection accuracy was 4.2± $$ \pm $$ 2.6 mm for the fetal eyes and 6.5± $$ \pm $$ 3.2 for the cerebellum, planning quality was 2.4/3 (compared to 2.6/3 for manual planning) and diagnostic image quality was 2.2 compared to 2.1 for manual planning.

CONCLUSIONS

Real-time automatic planning of all three key fetal brain planes was successfully achieved and will pave the way toward simplifying the acquisition of fetal MRI thereby widening the availability of this modality in nonspecialist centers.

Preeclampsia Associated Differences in the Placenta, Fetal Brain, and Maternal Heart Can Be Demonstrated Antenatally: An Observational Cohort Study Using MRI

BACKGROUND

Preeclampsia is a multiorgan disease of pregnancy that has short- and long-term implications for the woman and fetus, whose immediate impact is poorly understood. We present a novel multiorgan approach to magnetic resonance imaging (MRI) investigation of preeclampsia, with the acquisition of maternal cardiac, placental, and fetal brain anatomic and functional imaging.

METHODS

An observational study was performed recruiting 3 groups of pregnant women: those with preeclampsia, chronic hypertension, or no medical complications. All women underwent a cardiac MRI, and pregnant women underwent a placental-fetal MRI. Cardiac analysis for structural, morphological, and flow data were undertaken; placenta and fetal brain volumetric and T2* (which describes relative tissue oxygenation) data were obtained. All results were corrected for gestational age. A nonpregnant cohort was identified for inclusion in the statistical shape analysis.

RESULTS

Seventy-eight MRIs were obtained during pregnancy. Cardiac MRI analysis demonstrated higher left ventricular mass in preeclampsia with 3-dimensional modeling revealing additional specific characteristics of eccentricity and outflow track remodeling. Pregnancies affected by preeclampsia demonstrated lower placental and fetal brain T2*. Within the preeclampsia group, 23% placental T2* results were consistent with controls, these were the only cases with normal placental histopathology. Fetal brain T2* results were consistent with normal controls in 31% of cases.

CONCLUSIONS

We present the first holistic assessment of the immediate implications of preeclampsia on maternal heart, placenta, and fetal brain. As well as having potential clinical implications for the risk stratification and management of women with preeclampsia, this gives an insight into the disease mechanism.

Fit for Purpose? The Suitability of Oral Health Outcome Measures to Inform Policy

KNOWLEDGE TRANSFER STATEMENT

Oral health research and program evaluation should consider alternative outcome measures for population oral health other than the DMFT index.

The role of placental insufficiency in spontaneous preterm birth: A literature review

Preterm Birth (delivery before 37 weeks of gestation) is the leading cause of childhood mortality and is also associated with significant morbidity both in the neonatal period and beyond. The aetiology of spontaneous preterm birth is unclear and likely multifactorial incorporating factors such as infection/inflammation and cervical injury. Placental insufficiency is emerging as an additional contributor to spontaneous preterm delivery; however, the mechanisms by which this occurs are not fully understood. Serum biomarkers and imaging techniques have been investigated as potential predictors of placental insufficiency, however none have yet been found to have a sufficient predictive value. This review examines the evidence for the role of the placenta in preterm birth, preterm prelabour rupture of the membranes and abruption as well as highlighting areas where further research is required.

Automated body organ segmentation, volumetry and population-averaged atlas for 3D motion-corrected T2-weighted fetal body MRI

Structural fetal body MRI provides true 3D information required for volumetry of fetal organs. However, current clinical and research practice primarily relies on manual slice-wise segmentation of raw T2-weighted stacks, which is time consuming, subject to inter- and intra-observer bias and affected by motion-corruption. Furthermore, there are no existing standard guidelines defining a universal approach to parcellation of fetal organs. This work produces the first parcellation protocol of the fetal body organs for motion-corrected 3D fetal body MRI. It includes 10 organ ROIs relevant to fetal quantitative volumetry studies. We also introduce the first population-averaged T2w MRI atlas of the fetal body. The protocol was used as a basis for training of a neural network for automated organ segmentation. It showed robust performance for different gestational ages. This solution minimises the need for manual editing and significantly reduces time. The general feasibility of the proposed pipeline was also assessed by analysis of organ growth charts created from automated parcellations of 91 normal control 3T MRI datasets that showed expected increase in volumetry during 22-38 weeks gestational age range.

Adrenal volumes in fetuses delivering prior to 32 weeks' gestation: An MRI pilot study

INTRODUCTION

Spontaneous preterm birth prior to 32 weeks' gestation accounts for 1% of all deliveries and is associated with high rates of morbidity and mortality. A total of 70% are associated with chorioamnionitis which increases the incidence of morbidity, but for which there is no noninvasive antenatal test. Fetal adrenal glands produce cortisol and dehydroepiandosterone-sulphate which upregulate prior to spontaneous preterm birth. Ultrasound suggests that adrenal volumes may increase prior to preterm birth, but studies are limited. This study aimed to: (i) demonstrate reproducibility of magnetic resonance imaging (MRI) derived adrenal volumetry; (ii) derive normal ranges of total adrenal volumes, and adrenal: body volume for normal; (iii) compare with those who have spontaneous very preterm birth; and (iv) correlate with histopathological chorioamnionitis.

MATERIAL AND METHODS

Patients at high risk of preterm birth prior to 32 weeks were prospectively recruited, and included if they did deliver prior to 32 weeks; a control group who delivered an uncomplicated pregnancy at term was also recruited. T2 weighted images of the entire uterus were obtained, and a deformable slice-to-volume method was used to reconstruct the fetal abdomen. Adrenal and body volumes were obtained via manual segmentation, and adrenal: body volume ratios generated. Normal ranges were created using control data. Differences between groups were investigated accounting for the effect of gestation by use of regression analysis. Placental histopathology was reviewed for pregnancies delivering preterm.

RESULTS

A total of 56 controls and 26 cases were included in the analysis. Volumetry was consistent between observers. Adrenal volumes were not higher in the case group (p = 0.2); adrenal: body volume ratios were higher (p = 0.011), persisting in the presence of chorioamnionitis (p = 0.017). A cluster of three pairs of adrenal glands below the fifth centile were noted among the cases all of whom had a protracted period at risk of preterm birth prior to MRI.

CONCLUSIONS

Adrenal: body volume ratios are significantly larger in fetuses who go on to deliver preterm than those delivering at term. Adrenal volumes were not significantly larger, we hypothesize that this could be due to an adrenal atrophy in fetuses with fulminating chorioamnionitis. A straightforward relationship of adrenal size being increased prior to preterm birth should not be assumed.

Preterm premature rupture of the membranes (PPROM): a study of patient experiences and support needs

BACKGROUND

Preterm prelabour rupture of membranes (PPROM) is a common obstetric condition but outcomes can vary depending on gestation. Significant maternal and foetal complications occur including preterm birth, infection, abruption, cord prolapse, pulmonary hypoplasia and even death. Although the need for psychological support is recognised it is unclear how much is actually offered to women and their families. This study aimed to survey the views of women and their families who have undergone PPROM in order to understand the care and psychological burden these families face.

METHODS

An online survey was conducted, recruiting women via social media with collaboration from the patient advocacy support group Little Heartbeats. Responses were collated where fields were binary or mean and standard deviations calculated. Framework analysis was used to identify and analyse themes in free text responses.

RESULTS

180PPROM pregnancies were described from 177 respondents. Although carewas variable and respondents were from across the world there werecommon themes. Five themes were highlighted which were: a lack ofbalanced information regarding the condition, support in decisionmaking and support with the process, specific psychological supportand ongoing psychological consequences of PPROM.

CONCLUSION

This survey highlights areas in which care needs to be improved for women with PPROM. Previous studies have shown that providing good care during the antenatal period reduces long-term psychological morbidity for the whole family. The need for support, with regard both to information provided to women and their families and their psychological support needs to be addressed urgently.

Functional MRI assessment of the lungs in fetuses that deliver very Preterm: An MRI pilot study

OBJECTIVES

To compare mean pulmonary T2* values and pulmonary volumes in fetuses that subsequently spontaneously delivered before 32 weeks with a control cohort with comparable gestational ages and to assess the value of mean pulmonary T2* as a predictor of preterm birth < 32 weeks' gestation.

METHODS

MRI datasets scanned at similar gestational ages were selected from fetuses who spontaneously delivered < 32 weeks of gestation and a control group who subsequently delivered at term with no complications. All women underwent a fetal MRI on a 3 T MRI imaging system. Sequences included T2-weighted single shot fast spin echo and T2* sequences, using gradient echo single shot echo planar sequencing of the fetal thorax. Motion correction was performed using slice-to-volume reconstruction and T2* maps generated using in-house pipelines. Lungs were manually segmented and volumes and mean T2* values calculated for both lungs combined and left and right lung separately. Linear regression was used to compare values between the preterm and control cohorts accounting for the effects of gestation. Receiver operating curves were generated for mean T2* values and pulmonary volume as predictors of preterm birth < 32 weeks' gestation.

RESULTS

Datasets from twenty-eight preterm and 74 control fetuses were suitable for analysis. MRI images were taken at similar fetal gestational ages (preterm cohort (mean ± SD) 24.9 ± 3.3 and control cohort (mean ± SD) 26.5 ± 3.0). Mean gestational age at delivery was 26.4 ± 3.3 for the preterm group and 39.9 ± 1.3 for the control group. Mean pulmonary T2* values remained constant with increasing gestational age while pulmonary volumes increased. Both T2* and pulmonary volumes were lower in the preterm group than in the control group for all parameters (both combined, left, and right lung (p < 0.001 in all cases). Adjusted for gestational age, pulmonary volumes and mean T2* values were good predictors of premature delivery in fetuses < 32 weeks (area under the curve of 0.828 and 0.754 respectively).

CONCLUSION

These findings indicate that mean pulmonary T2* values and volumes were lower in fetuses that subsequently delivered very preterm. This may suggest potentially altered oxygenation and indicate that pulmonary morbidity associated with prematurity has an antenatal antecedent. Future work should explore these results correlating antenatal findings with long term pulmonary outcomes.

Effective and simple interventions to improve outcomes for preterm infants worldwide: The FIGO PremPrep-5 initiative

Preterm birth remains the leading cause of mortality among under-5's and is a major contributor to the reduction in quality-of-life adjusted years and reduction in human capital. Globally, there are many interventions and care bundles that aim to reduce the impact of preterm birth once preterm labor has ensued and into the neonatal period; not all of these are applicable in all settings. Here, we introduce the FIGO PremPrep-5 initiative, which aims to disseminate key information on the most simple and effective interventions with the aim of increasing implementation globally. Before delivery, we recommend a course of antenatal corticosteroids, and intrapartum magnesium sulfate. At delivery, we recommend delayed cord clamping. Postnatally, we recommend early feeding with breast milk and immediate kangaroo care. While there are many other interventions that may improve outcomes at the time of labor and after preterm birth, these are clinically effective and relatively inexpensive options that can be practiced in most settings and supplemented with more advanced care. We include examples of a training video and infographics that will be used for dissemination.

Advanced magnetic resonance imaging detects altered placental development in pregnancies affected by congenital heart disease

Congenital heart disease (CHD) is the most common congenital malformation and is associated with adverse neurodevelopmental outcomes. The placenta is crucial for healthy fetal development and placental development is altered in pregnancy when the fetus has CHD. This study utilized advanced combined diffusion-relaxation MRI and a data-driven analysis technique to test the hypothesis that placental microstructure and perfusion are altered in CHD-affected pregnancies. 48 participants (36 controls, 12 CHD) underwent 67 MRI scans (50 control, 17 CHD). Significant differences in the weighting of two independent placental and uterine-wall tissue components were identified between the CHD and control groups (both pFDR<0.001), with changes most evident after 30 weeks gestation. A Significant trend over gestation in weighting for a third independent tissue component was also observed in the CHD cohort (R = 0.50, pFDR=0.04), but not in controls. These findings add to existing evidence that placental development is altered in CHD. The results may reflect alterations in placental perfusion or the changes in fetal-placental flow, villous structure and maturation that occur in CHD. Further research is needed to validate and better understand these findings and to understand the relationship between placental development, CHD, and its neurodevelopmental implications.

Perspectives of Healthcare Professionals on the Management and Treatment of Advanced Ovarian Cancer in the UK: Results From the KNOW-OC Survey

AIMS

New treatment options for advanced ovarian cancer have the potential to significantly change the treatment pathway in the UK. Understanding the structures and responsibilities of multidisciplinary teams/tumour boards (MDT) and regional variations will enable services to adapt more effectively to these changes.

MATERIALS AND METHODS

The KNOW-OC survey was conducted in 2020 to understand the views of a selected group of 66 healthcare professionals (HCPs) involved in advanced ovarian cancer care in UK hospitals.

RESULTS

The results showed that MDT involvement in the management of advanced ovarian cancer varied depending on pathway stage and line of relapse, with 98.5% of HCPs responding that the MDT was involved in decisions at initial presentation, but only 40.9% for patients with multiple relapses. The MDT was mostly responsible for determining whether the patients would undergo primary or interval cytoreductive surgery according to 75.8% of respondents, and most HCPs (80.3%) stated that tumour dissemination patterns were the most important factor influencing this decision. The most commonly assessed biomarkers at the time of the survey were CA125, gBRCA and tBRCA. Homologous recombination deficiency was viewed as the second most important factor for determining prognosis, but few centres had access to testing at the time of survey completion. The use of active surveillance was expected to decrease in favour of first-line targeted therapies. Nearly all (98.5%) HCPs agreed there is a role for secondary cytoreductive surgery for the treatment of recurrence (for carefully selected patients).

CONCLUSIONS

The results highlighted UK-specific geographical variation in the views of HCPs on MDT involvement and specific practices, such as molecular biomarker testing, and the overall treatment approach. Together, these findings improve the understanding of reported clinical practice across the UK for ovarian cancer and provide insight into decision-making associated with updates to recommendations for best practice (e.g. European Society for Medical Oncology/European Society of Gynaecological Oncology consensus statements) and the introduction of new treatment options.

Functional assessment of brain development in fetuses that subsequently deliver very preterm: An MRI pilot study

OBJECTIVES

To evaluate changes occurring in the fetal brain prior to very preterm delivery using MRI T2* relaxometry, an indirect assessment of tissue perfusion.

METHOD

Fetuses that subsequently delivered spontaneously <32 weeks gestation and a control cohort were identified from pre-existing datasets. Participants had undergone a 3T MRI assessment including T2* relaxometry of the fetal brain using a 2D multi-slice gradient echo single shot echo planar imaging sequence. T2* maps were generated, supratentorial brain tissue was manually segmented and mean T2* values were generated. Groups were compared using quadratic regression.

RESULTS

Twenty five fetuses that subsequently delivered <32 weeks and 67 that delivered at term were included. Mean gestation at MRI was 24.5 weeks (SD 3.3) and 25.4 weeks (SD 3.1) and gestation at delivery 25.5 weeks (SD 3.4) and 39.7 weeks (SD 1.2) in the preterm and term cohorts respectively. Brain mean T2* values were significantly lower in fetuses that subsequently delivered before 32 weeks gestation (p < 0.001).

CONCLUSION

Alterations in brain maturation appear to occur prior to preterm delivery. Further work is required to explore these associations, but these findings suggest a potential window for therapeutic neuroprotective agents in fetuses at high risk of preterm delivery in the future.

Fetal growth restriction: How reliable is information available to patients on Google? A systematic review

OBJECTIVES

To review systematically the quality, readability and credibility of English language webpages offering patient information on fetal growth restriction.

STUDY DESIGN

A systematic review of patient information was undertaken on Google with location services and browser history disabled. Websites from the first page were included providing they gave at least 300 words of health information on fetal growth restriction aimed at patients. Validated assessment of readability, credibility and quality were undertaken. An accuracy assessment was performed based on international guidance. Characteristics were tabulated.

RESULTS

Thirty-one websites including 30 different texts were included. No pages had a reading age of 11 years or less, none were credible, and only one was of high quality. Median accuracy rating was 9/24.

CONCLUSION

Patients cannot rely on Google as a source of information on fetal growth restriction. As well as being difficult to read, information tends to be low quality, low accuracy and not credible. Healthcare professionals must consider how to enable access to high-quality patient information and give time for discussion of information patients have found: failure to do so may disenfranchise patients.

Amniotic fluid sludge is associated with earlier preterm delivery and raised cervicovaginal interleukin 8 concentrations

BACKGROUND

Preterm birth is the leading cause of global neonatal mortality. Amniotic fluid sludge, thought to indicate intra-amniotic infection, may have potential as a clinical biomarker of preterm birth risk.

OBJECTIVE

This study aimed to analyze whether the presence of amniotic fluid sludge in pregnant participants with a known short cervical length can help improve the understanding of the etiology and guide management choice.

STUDY DESIGN

This was a retrospective cohort study analyzing the effects of amniotic fluid sludge presence on the risk of preterm birth in high-risk asymptomatic pregnant participants with a short cervical length (<25 mm) at a large tertiary referral maternity center in London. Amniotic fluid sludge was detected on a routine transvaginal ultrasound scan.

RESULTS

Overall, 147 pregnant participants with a short cervical length were identified, 54 of whom had amniotic fluid sludge. Compared with pregnant participants without amniotic fluid sludge, pregnant participants with amniotic fluid sludge were more likely to have a short cervical length (19 vs 14 mm, respectively; P<.0001) and increased cervicovaginal fetal fibronectin concentrations at diagnosis (125 vs 45 ng/mL, respectively; P=.0006). Pregnant participants with amniotic fluid sludge were at increased risk of midtrimester loss and delivery before 24 weeks of gestation (relative risk, 3.4; 95% confidence interval, 1.2-10.3). Furthermore, this study showed that pregnant participants with amniotic fluid sludge have increased cervicovaginal interleukin 8 concentrations, supporting the concept of amniotic fluid sludge as an indicator of an inflammatory response to microbial invasion (P=.03). Neonatal outcomes were similar between the 2 groups.

CONCLUSION

In our cohort of high-risk asymptomatic pregnant participants with a short cervical length, the presence of amniotic fluid sludge is associated with an increased risk of delivery before 24 weeks of gestation. Moreover, pregnant participants with amniotic fluid sludge were more likely to have raised fetal fibronectin levels and inflammatory cytokines, particularly interleukin 8, in the cervicovaginal fluid, supporting the concept that amniotic fluid sludge is associated with an infective or inflammatory process. Future research should aim to further establish the clinical significance of amniotic fluid sludge presence and guide subsequent management.

Modelling TDP-43 proteinopathy in Drosophila uncovers shared and neuron-specific targets across ALS and FTD relevant circuits

Amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD) comprise a spectrum of neurodegenerative diseases linked to TDP-43 proteinopathy, which at the cellular level, is characterized by loss of nuclear TDP-43 and accumulation of cytoplasmic TDP-43 inclusions that ultimately cause RNA processing defects including dysregulation of splicing, mRNA transport and translation. Complementing our previous work in motor neurons, here we report a novel model of TDP-43 proteinopathy based on overexpression of TDP-43 in a subset of Drosophila Kenyon cells of the mushroom body (MB), a circuit with structural characteristics reminiscent of vertebrate cortical networks. This model recapitulates several aspects of dementia-relevant pathological features including age-dependent neuronal loss, nuclear depletion and cytoplasmic accumulation of TDP-43, and behavioral deficits in working memory and sleep that occur prior to axonal degeneration. RNA immunoprecipitations identify several candidate mRNA targets of TDP-43 in MBs, some of which are unique to the MB circuit and others that are shared with motor neurons. Among the latter is the glypican Dally-like-protein (Dlp), which exhibits significant TDP-43 associated reduction in expression during aging. Using genetic interactions we show that overexpression of Dlp in MBs mitigates TDP-43 dependent working memory deficits, conistent with Dlp acting as a mediator of TDP-43 toxicity. Substantiating our findings in the fly model, we find that the expression of GPC6 mRNA, a human ortholog of dlp, is specifically altered in neurons exhibiting the molecular signature of TDP-43 pathology in FTD patient brains. These findings suggest that circuit-specific Drosophila models provide a platform for uncovering shared or disease-specific molecular mechanisms and vulnerabilities across the spectrum of TDP-43 proteinopathies.

Reliability and Feasibility of Low-Field-Strength Fetal MRI at 0.55 T during Pregnancy

Background The benefits of using low-field-strength fetal MRI to evaluate antenatal development include reduced image artifacts, increased comfort, larger bore size, and potentially reduced costs, but studies about fetal low-field-strength MRI are lacking. Purpose To evaluate the reliability and feasibility of low-field-strength fetal MRI to assess anatomic and functional measures in pregnant participants using a commercially available 0.55-T MRI scanner and a comprehensive 20-minute protocol. Materials and Methods This prospective study was performed at a large teaching hospital (St Thomas' Hospital; London, England) from May to November 2022 in healthy pregnant participants and participants with pregnancy-related abnormalities using a commercially available 0.55-T MRI scanner. A 20-minute protocol was acquired including anatomic T2-weighted fast-spin-echo, quantitative T2*, and diffusion sequences. Key measures like biparietal diameter, transcerebellar diameter, lung volume, and cervical length were evaluated by two radiologists and an MRI-experienced obstetrician. Functional organ-specific mean values were given. Comparison was performed with existing published values and higher-field MRI using linear regression, interobserver correlation, and Bland-Altman plots. Results A total of 79 fetal MRI examinations were performed (mean gestational age, 29.4 weeks ± 5.5 [SD] [age range, 17.6-39.3 weeks]; maternal age, 34.4 years ± 5.3 [age range, 18.4-45.5 years]) in 47 healthy pregnant participants (control participants) and in 32 participants with pregnancy-related abnormalities. The key anatomic two-dimensional measures for the 47 healthy participants agreed with large cross-sectional 1.5-T and 3-T control studies. The interobserver correlations for the biparietal diameter in the first 40 consecutive scans were 0.96 (95% CI: 0.7, 0.99; P = .002) for abnormalities and 0.93 (95% CI: 0.86, 0.97; P < .001) for control participants. Functional features, including placental and brain T2* and placental apparent diffusion coefficient values, strongly correlated with gestational age (mean placental T2* in the control participants: 5.2 msec of decay per week; R2 = 0.66; mean T2* at 30 weeks, 176.6 msec; P < .001). Conclusion The 20-minute low-field-strength fetal MRI examination protocol was capable of producing reliable structural and functional measures of the fetus and placenta in pregnancy. Clinical trial registration no. REC 21/LO/0742 © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Gowland in this issue.

Googling preterm prelabour rupture of the membranes: A systematic review of patient information available on the internet

BACKGROUND

Preterm prelabour rupture of the membranes (PPROM) complicates 3% of pregnancies and is associated with an increased risk of maternal and perinatal morbidity and mortality. In an attempt to better understand this diagnosis, patients routinely resort to the internet for medical information. The lack of governance online leaves patients at risk of relying on low-quality websites.

OBJECTIVES

To assess systematically the accuracy, quality, readability and credibility of World Wide Web pages on PPROM.

SEARCH STRATEGY

Five search engines (Google, AOL, Yahoo, Ask and Bing) were searched with location services and browser history disabled. Websites from the first page of all searches were included.

SELECTION CRITERIA

Websites were included if they provided at least 300 words of health information aimed at patients relating to PPROM.

DATA COLLECTION AND ANALYSIS

Validated assessments of health information readability, credibility and quality were undertaken, as was an accuracy assessment. Pertinent facts for accuracy assessment were based on feedback from healthcare professionals and patients through a survey. Characteristics were tabulated.

MAIN RESULTS

In all, 39 websites were included, with 31 different texts. No pages were written with a reading age of 11 years or less, none were considered credible, and only three were high quality. An accuracy score of 50% or more was obtained by 45% of websites. Information that patients considered pertinent was not consistently reported.

CONCLUSIONS

Search engines produce information on PPROM that is low quality, low accuracy and not credible. It is also difficult to read. This risks disempowerment. Healthcare professionals and researchers must consider how to ensure patients have access to information that they can recognise as high quality.

Clinical value of placental examination for paediatricians

The placenta contains valuable clinical information that is linked to fetal development, neonatal morbidity and mortality, and future health outcomes. Both gross inspection and histopathological examination of the placenta may identify intrinsic or secondary placental lesions, which can contribute directly to adverse neonatal outcomes or indicate the presence of an unfavourable intrauterine environment. Placental examination therefore forms an essential component of the care of high-risk neonates and at perinatal post-mortem examination. In this article, we describe the clinical value of placental examination for paediatricians and perinatal clinicians. We discuss common pathological findings on general inspection of the placenta with photographic examples and provide an overview of the placental pathological examination, including how to interpret key findings. We also address the medico-legal and financial implications of placental examinations and describe current and future clinical considerations for clinicians in regard to placental examination.

3D T2w fetal body MRI: automated organ volumetry, growth charts and population-averaged atlas

Structural fetal body MRI provides true 3D information required for volumetry of fetal organs. However, current clinical and research practice primarily relies on manual slice-wise segmentation of raw T2-weighted stacks, which is time consuming, subject to inter- and intra-observer bias and affected by motion-corruption. Furthermore, there are no existing standard guidelines defining a universal approach to parcellation of fetal organs. This work produces the first parcellation protocol of the fetal body organs for motion-corrected 3D fetal body MRI. It includes 10 organ ROIs relevant to fetal quantitative volumetry studies. We also introduce the first population-averaged T2w MRI atlas of the fetal body. The protocol was used as a basis for training of a neural network for automated organ segmentation. It showed robust performance for different gestational ages. This solution minimises the need for manual editing and significantly reduces time. The general feasibility of the proposed pipeline was also assessed by analysis of organ growth charts created from automated parcellations of 91 normal control 3T MRI datasets that showed expected increase in volumetry during 22-38 weeks gestational age range. In addition, the results of comparison between 60 normal and 12 fetal growth restriction datasets revealed significant differences in organ volumes.

A content review of state tobacco pre-emption laws in the US

OBJECTIVES

State ceiling pre-emption laws effectively limit the authority of local governments to regulate numerous public health issues, including tobacco. While general trends in the number of state tobacco pre-emption laws have been well-documented, less is known about the specific content of these laws. This study provides a comprehensive analysis of the content of current state tobacco pre-emption laws and captures the salient features of these laws.

STUDY DESIGN

This was a comparative analysis of tobacco pre-emption laws in the United States.

METHODS

The study team collected data about tobacco pre-emption laws from the Centers for Disease Control and Prevention's State Tobacco Activities Tracking and Evaluation System. Trained legal researchers further verified and reviewed each law's content using the Westlaw database. A coding scheme was developed to capture and analyse these laws' most salient features.

RESULTS

State tobacco pre-emption laws use various terms to indicate the pre-emption of a local authority, including supersede, pre-empt, uniform, exclusive, and consistent. State laws cover numerous general topics and vary widely in explicit terminology of authorities and fields pre-empted. Several state laws included grandfathering exceptions and a few allowed exceptions for particular local jurisdictions.

CONCLUSIONS

State laws that undermine local tobacco control efforts from implementing more stringent laws pose a threat to public health. These laws vary widely in their scope across the U.S., and local jurisdictions should be empowered to enact and maintain tobacco control measures that protect their communities from the harms of tobacco use and exposure.

An automated pipeline for quantitative T2* fetal body MRI and segmentation at low field

Fetal Magnetic Resonance Imaging at low field strengths is emerging as an exciting direction in perinatal health. Clinical low field (0.55T) scanners are beneficial for fetal imaging due to their reduced susceptibility-induced artefacts, increased T2* values, and wider bore (widening access for the increasingly obese pregnant population). However, the lack of standard automated image processing tools such as segmentation and reconstruction hampers wider clinical use. In this study, we introduce a semi-automatic pipeline using quantitative MRI for the fetal body at low field strength resulting in fast and detailed quantitative T2* relaxometry analysis of all major fetal body organs. Multi-echo dynamic sequences of the fetal body were acquired and reconstructed into a single high-resolution volume using deformable slice-to-volume reconstruction, generating both structural and quantitative T2* 3D volumes. A neural network trained using a semi-supervised approach was created to automatically segment these fetal body 3D volumes into ten different organs (resulting in dice values > 0.74 for 8 out of 10 organs). The T2* values revealed a strong relationship with GA in the lungs, liver, and kidney parenchyma (R2 >0.5). This pipeline was used successfully for a wide range of GAs (17-40 weeks), and is robust to motion artefacts. Low field fetal MRI can be used to perform advanced MRI analysis, and is a viable option for clinical scanning.

Cervical cerclage technique: what do experts actually achieve?

BACKGROUND

Cervical cerclage is a recognized intervention in the management of women at risk of preterm birth and midtrimester loss. The mechanism of action of cerclage is unclear, and the technique has been poorly researched.

OBJECTIVE

This study aimed to evaluate cerclage technique among experienced obstetricians, using a previously developed and evaluated cerclage simulator.

STUDY DESIGN

This prospective experimental simulation and observational study used identical simulators for 28 consultant obstetricians who were asked to perform their normal cerclage. Suture type, height, knot site, and free thread length were recorded. Using computed tomography, depth of bite and tension (by reduction in area of cervix) were calculated.

RESULTS

A total of 52 cervical cerclages were completed (Mersilene tape, n=20; monofilament suture, n=32). Mean suture height was 33 mm (standard deviation, 7.7 mm), greater with monofilament suture than with Mersilene tape, and associated with smaller needle size. Mean depth of bite and mean reduction of starting area did not differ by suture type. Seven procedures showed ≥1 suture bite that had entered the cervical canal once or more.

CONCLUSION

This study assessed cerclage technique of experienced obstetricians using simulators and computed tomography imaging, and demonstrated wide variation in technique; this may affect the efficacy of the procedure. Further work should establish optimal technique and consensus for training and clinical practice.

Assessment of normal pulmonary development using functional magnetic resonance imaging techniques

BACKGROUND

The mainstay of assessment of the fetal lungs in clinical practice is via evaluation of pulmonary size, primarily using 2D ultrasound and more recently with anatomical magnetic resonance imaging. The emergence of advanced magnetic resonance techniques such as T2* relaxometry in combination with the latest motion correction post-processing tools now facilitates assessment of the metabolic activity or perfusion of fetal pulmonary tissue in vivo.

OBJECTIVE

This study aimed to characterize normal pulmonary development using T2* relaxometry, accounting for fetal motion across gestation.

METHODS

Datasets from women with uncomplicated pregnancies that delivered at term, were analyzed. All subjects had undergone T2-weighted imaging and T2* relaxometry on a Phillips 3T magnetic resonance imaging system antenatally. T2* relaxometry of the fetal thorax was performed using a gradient echo single-shot echo planar imaging sequence. Following correction for fetal motion using slice-to-volume reconstruction, T2* maps were generated using in-house pipelines. Lungs were manually segmented and mean T2* values calculated for the right and left lungs individually, and for both lungs combined. Lung volumes were generated from the segmented images, and the right and left lungs, as well as both lungs combined were assessed.

RESULTS

Eighty-seven datasets were suitable for analysis. The mean gestation at scan was 29.9±4.3 weeks (range: 20.6-38.3) and mean gestation at delivery was 40±1.2 weeks (range: 37.1-42.4). Mean T2* values of the lungs increased over gestation for right and left lungs individually and for both lungs assessed together (P=.003; P=.04; P=.003, respectively). Right, left, and total lung volumes were also strongly correlated with increasing gestational age (P<.001 in all cases).

CONCLUSION

This large study assessed developing lungs using T2* imaging across a wide gestational age range. Mean T2* values increased with gestational age, which may reflect increasing perfusion and metabolic requirements and alterations in tissue composition as gestation advances. In the future, evaluation of findings in fetuses with conditions known to be associated with pulmonary morbidity may lead to enhanced prognostication antenatally, consequently improving counseling and perinatal care planning.

Characterisation of placental, fetal brain and maternal cardiac structure and function in pre-eclampsia using MRI

Background

Pre-eclampsia is a multiorgan disease of pregnancy that has short- and long-term implications for the woman and fetus, whose immediate impact is poorly understood. We present a novel multi-system approach to MRI investigation of pre-eclampsia, with acquisition of maternal cardiac, placental, and fetal brain anatomical and functional imaging.

Methods

A prospective study was carried out recruiting pregnant women with pre-eclampsia, chronic hypertension, or no medical complications, and a non-pregnant female cohort. All women underwent a cardiac MRI, and pregnant women underwent a fetal-placental MRI. Cardiac analysis for structural, morphological and flow data was undertaken; placenta and fetal brain volumetric and T2* data were obtained. All results were corrected for gestational age.

Results

Seventy-eight MRIs were obtained during pregnancy. Pregnancies affected by pre-eclampsia demonstrated lower placental and fetal brain T2*. Within the pre-eclampsia group, three placental T2* results were within the normal range, these were the only cases with normal placental histopathology. Similarly, three fetal brain T2* results were within the normal range; these cases had no evidence of cerebral redistribution on fetal Dopplers. Cardiac MRI analysis demonstrated higher left ventricular mass in pre-eclampsia with 3D modelling revealing additional specific characteristics of eccentricity and outflow track remodelling.

Conclusions

We present the first holistic assessment of the immediate implications of pre-eclampsia on the placenta, maternal heart, and fetal brain. As well as having potential clinical implications for the risk-stratification and management of women with pre-eclampsia, this gives an insight into disease mechanism.

Multi-modal MRI reveals changes in placental function following preterm premature rupture of membranes

PURPOSE

Preterm premature rupture of membranes complicates up to 40% of premature deliveries. Fetal infection may occur in the absence of maternal symptoms, delaying diagnosis and increasing morbidity and mortality. A noninvasive antenatal assessment of early signs of placental inflammation is therefore urgently required.

METHODS

Sixteen women with preterm premature rupture of membranes < 34 weeks gestation and 60 women with uncomplicated pregnancies were prospectively recruited. A modified diffusion-weighted spin-echo single shot EPI sequence with a diffusion preparation acquiring 264 unique parameter combinations in < 9 min was obtained on a clinical 3 Tesla MRI scanner. The data was fitted to a 2-compartment T 2 * $$ {\mathrm{T}}_2^{\ast } $$ -intravoxel incoherent motion model comprising fast and slowly circulating fluid pools to obtain quantitative information on perfusion, density, and tissue composition. Z values were calculated, and correlation with time from between the rupture of membranes and the scan, gestational age at delivery, and time between scan and delivery assessed.

RESULTS

Placental T 2 * $$ {\mathrm{T}}_2^{\ast } $$ was significantly reduced in preterm premature rupture of membranes, and the 2-compartmental model demonstrated that this decline is mainly linked to the perfusion component observed in the placental parenchyma. Multi-modal MRI measurement of placental function is linked to gestational age at delivery and time from membrane rupture.

CONCLUSION

More complex models and data acquisition can potentially improve fitting of the underlying etiology of preterm birth compared with individual single-contrast models and contribute to additional insights in the future. This will need validation in larger cohorts. A multi-modal MRI acquisition between rupture of the membranes and delivery can be used to measure placental function and is linked to gestational age at delivery.

Cervical cerclage training: Development and assessment of a simulator

BACKGROUND

Cervical cerclage is a mainstay intervention for the prevention of spontaneous preterm birth in high-risk women. Simulation training facilitates high-level skill transfer in a low-consequence environment, and is being integrated into obstetrics and gynecology training.

OBJECTIVE

This study aimed to develop a simulator for cervical cerclage, determine its validity as a simulator, and identify parameters suitable as proxy markers for performance.

STUDY DESIGN

The 3 aims of this study were achieved, namely: (1) simulator design by obstetricians and a commercial company; (2) survey of obstetricians and gynecologists across a variety of training stages to determine need for and opinion of the simulator; and (3) comparison of novice and expert groups across a variety of proxy markers for successful cerclage insertion.

RESULTS

Obstetricians and gynecologists found the simulator to be similar to clinical scenarios and suitable for skill training. Novice participants stated that the use of the simulator improved their confidence (P=.016). In a comparison between 6 expert and 8 novice surgeons, there seemed to be variations across multiple measurements of cerclage placement.

CONCLUSION

Simulation is an increasingly prominent training modality for surgical skills. The simulator described herein was considered suitable for training by obstetricians and gynecologists. Further work should focus on the validations of proxy markers of successful insertion, longitudinal assessment of trainees, and correlation of training outcomes with clinical outcomes.

A clinical study comparing polymer and gold fiducials for prostate cancer radiotherapy

Introduction

Image guidance with gold fiducials improves outcomes of prostate radiotherapy. However, gold produces artefact on CT imaging, interfering with contouring and verification. The purpose of this study was to compare polymer to standard gold fiducials using radiotherapy imaging modalities to assess the visibility and artefact.

Methods

Twenty eight patients with locally advanced prostate cancer were enrolled, half had three polymer fiducials implanted into the prostate and half underwent insertion of gold fiducials. Patients were imaged with CT, T2 weighted MRI, cone-beam CT (CBCT) and planar KV images. Fiducials were scored for visibility and assessed for CT artefact in surrounding prostate tissue. The artefact was quantified from Hounsfield number histograms and separated into percentile ranges and proportion of voxels in HU normal tissue range of a 2cm sphere surrounding the fiducial.

Results

Gold and polymer fiducials were sufficiently visible for CT and CBCT verification. The gold fiducials could be visualized well on KV planar imaging; however, the polymer markers were obscured by pelvic bones. Neither polymer nor gold fiducials could be visualized on MRI. The polymer fiducial produced less artefact than gold on CT, having less voxel spread for the HU percentile ranges and a greater proportion of voxels in the normal tissue range.

Conclusions

Polymer fiducials are a more suitable fiducial than gold for CT/CBCT in prostate cancer radiotherapy, demonstrating minimal artefact and good visibility on CT. However, they were not well seen on MRI or KV imaging and thus not suitable for co-registration or planar KV verification.

The time is now: making the case for a UK registry of deployment of radiology artificial intelligence applications

Artificial intelligence (AI)-based healthcare applications (apps) are rapidly evolving, and radiology is a target specialty for their implementation. In this paper, we put the case for a national deployment registry to track the spread of AI apps into clinical use in radiology in the UK. By gathering data on the specific locations, purposes, and people associated with AI app deployment, such a registry would provide greater transparency on their spread in the radiology field. In combination with other regulatory and audit mechanisms, it would provide radiologists and patients with greater confidence and trust in AI apps. At the same time, coordination of this information would reduce costs for the National Health Service (NHS) by preventing duplication of piloting activities. This commentary discusses the need for a UK-wide registry for such apps, its benefits and risks, and critical success factors for its establishment. We conclude by noting that a critical window of opportunity has opened up for the development of a deployment registry, before the current pattern of localised clusters of activity turns into the widespread proliferation of AI apps across clinical practice.

Assessment of the fetal lungs in utero

Antenatal diagnosis of abnormal pulmonary development has improved significantly over recent years because of progress in imaging techniques. Two-dimensional ultrasound is the mainstay of investigation of pulmonary pathology during pregnancy, providing good prognostication in conditions such as congenital diaphragmatic hernia; however, it is less validated in other high-risk groups such as those with congenital pulmonary airway malformation or preterm premature rupture of membranes. Three-dimensional assessment of lung volume and size is now possible using ultrasound or magnetic resonance imaging; however, the use of these techniques is still limited because of unpredictable fetal motion, and such tools have also been inadequately validated in high-risk populations other than those with congenital diaphragmatic hernia. The advent of advanced, functional magnetic resonance imaging techniques such as diffusion and T2* imaging, and the development of postprocessing pipelines that facilitate motion correction, have enabled not only more accurate evaluation of pulmonary size, but also assessment of tissue microstructure and perfusion. In the future, fetal magnetic resonance imaging may have an increasing role in the prognostication of pulmonary abnormalities and in monitoring current and future antenatal therapies to enhance lung development. This review aims to examine the current imaging methods available for assessment of antenatal lung development and to outline possible future directions.

COVID-19 vaccine hesitancy: a midwifery survey into attitudes towards the COVID-19 vaccine

Background

Ethnically minoritised people have been disproportionately affected by the COVID-19 pandemic. Emerging evidence suggests a lower uptake of the vaccine in ethnically minoritised people, particularly Black females of reproductive age. Unvaccinated pregnant women are high risk for morbidity and mortality from COVID-19. Midwives are the principal healthcare professionals responsible for counselling the pregnant population on decisions relating to vaccine uptake. The aim of this study was to explore midwifery uptake of and attitudes towards the COVID-19 vaccine in two ethnically diverse areas.

Methods

A 45-point questionnaire was circulated over a six-week period to midwives employed in two teaching hospitals in England; London (Barts Health NHS Trust) and Sussex (Brighton and Sussex University Hospitals NHS Trust (BSUH)). A total of 378 out of 868 midwives responded. Results were analysed to determine vaccine uptake as well as factors influencing vaccine hesitancy and decision-making between the two trusts and ethnic groups. Thematic analysis was also undertaken.

Results

Midwives of Black ethnicities were over 4-times less likely to have received a COVID-19 vaccine compared to midwives of White ethnicities (52% vs 85%, adjusted OR = 0.22, p = < 0.001). Overall, there were no significant differences between trusts in receipt of the COVID-19 vaccine (p = 0.13). Midwives at Barts Health were significantly more likely to have tested positive for COVID-19 compared to midwives at BSUH (adjusted OR = 2.55, p = 0.007). There was no statistical difference between ethnicities in testing positive for COVID-19 (p = 0.86). The most common concerns amongst all participants were regarding the long-term effect of the vaccine (35%), that it was developed too fast (24%), having an allergic reaction (22%) and concerns about fertility (15%). Amongst unvaccinated midwives, those of Black ethnicity had a higher occurrence of concern that the vaccine contained meat / porcine products (adjusted OR = 5.93, p = 0.04) and that the vaccine would have an adverse effect on ethnic minorities (adjusted OR = 4.42, p = 0.03).

Conclusion

This study highlights the significantly higher level of vaccine hesitancy amongst Black midwives and offer insights into midwives’ concerns. This can facilitate future targeted public health interventions. It is essential that vaccine hesitancy amongst midwifery staff is addressed to improve vaccine uptake in the pregnant population.

Antenatal diagnosis of chorioamnionitis: A review of the potential role of fetal and placental imaging

Chorioamnionitis is present in up to 70% of spontaneous preterm births. It is defined as an acute inflammation of the chorion, with or without involvement of the amnion, and is evidence of a maternal immunological response to infection. A fetal inflammatory response can coexist and is diagnosed on placental histopathology postnatally. Fetal inflammatory response syndrome (FIRS) is associated with poorer fetal and neonatal outcomes. The only antenatal diagnostic test is amniocentesis which carries risks of miscarriage or preterm birth. Imaging of the fetal immune system, in particular the thymus and the spleen, and the placenta may give valuable information antenatally regarding the diagnosis of fetal inflammatory response. While ultrasound is largely limited to structural information, MRI can complement this with functional information that may provide insight into the metabolic activities of the fetal immune system and placenta. This review discusses fetal and placental imaging in pregnancies complicated by chorioamnionitis and their potential future use in achieving non-invasive antenatal diagnosis. This article is protected by copyright. All rights reserved.

POS1521-HPR UNDERSTANDING AND IDENTIFYING KEY CONTEXTUAL FACTORS THAT INFLUENCE THE PRACTITIONER-PATIENT ENCOUNTER IN THE MANAGEMENT OF OSTEOARTHRITIS: A QUALITATIVE SYSTEMATIC REVIEW

Background

Contextual factors (CFs) related to the patient, healthcare practitioners, and their therapeutic relationship are integral to the overall treatment effect of any given intervention (1). In osteoarthritis (OA), around 75% of the treatment effect is directly attributable to CFs (2). Identifying and understanding the role of CFs may encourage healthcare practitioners to develop and enhance the contextual aspects of care.

Objectives

To explore and understand the experience and perspectives of patients and health practitioners regarding CFs in consultations for OA.

Methods

A systematic search was conducted between March 15 and May 18, 2020, on the following databases: MEDLINE via Ovid, EMBASE, AMED, PsycINFO and CINAHL. The search for unpublished studies included ProQuest Dissertations and Google Scholar. The search was not limited to any language or publication year. The Joanna Briggs Institute (JBI) methodology for quality assessment, study selection, data extraction and synthesis were used. Findings were assessed for credibility, categorised based on similarity in meaning and subjected to a meta-aggregation. The ConQual approach was used to assess the confidence of the synthesised findings (3).

Results

Of 1808 records generated from the systematic search of databases and grey literature, eight studies were included in the meta-aggregation (Figure 1). All included papers were moderate to high quality based on the JBI qualitative critical appraisal tool. Meta-aggregation generated three synthesised findings. According to the ConQual criteria, all the synthesised findings’ level of evidence was rated as moderate (Table 1). The key, potentially modifiable, factors identified were positive communication; clear and relevant information provided by the health practitioner; patient expectation concerning their outcome and the consultation experience; sufficient consultation time; and easy access to consultations.

Table 1.

ConQual summary of findings

Synthesized findingType of researchDependabilityCredibilityConQual scoreI. People with OA will likely experience comprehensive and satisfactory management of their condition if the key contextual enhancers are implemented.QualitativeUnchanged*Downgrade 1 level**ModerateII. Health providers acknowledged that information provision and efficient communication skills are likely to enhance management during consultations for OA.QualitativeUnchanged*Downgrade 1 level**ModerateIII. Effective consultations are affected by an intersection of organizational challenges and patient and provider characteristics. Limited experience with OA of some practitioners, unrealistic patients’ expectations, and short consultation duration are barriers that need to be adjusted for better management.QualitativeUnchanged*Downgrade 1 level**Moderate

* The average score was (4/5) for dependability.

** Downgraded one level due to a mix of unequivocal and credible findings.

Figure 1.

PRISMA flowchart of the study selection and inclusion process

Conclusion

This qualitative systematic review has defined three synthesized findings. Identification of modifiable CFs that are deemed important by both patients and health practitioners can inform the development of a training package for healthcare professional.

References

[1]Di Blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context effects on health outcomes: a systematic review. The Lancet. 2001;357(9258):757-762.

[2]Zou K, Wong J, Abdullah N, Chen X, Smith T, Doherty M et al. Examination of overall treatment effect and the proportion attributable to contextual effect in osteoarthritis: meta-analysis of randomised controlled trials. Annals of the Rheumatic Diseases. 2016;75(11):1964-1970.

[3]Munn, Z., Porritt, K., Lockwood, C., Aromataris, E. & Pearson, A. 2014. Establishing confidence in the output of qualitative research synthesis: the ConQual approach. BMC medical research methodology, 14, 1-7.

Disclosure of Interests

None declared

Walking-related knee contact forces and associations with knee pain across people with mild, moderate and severe radiographic knee osteoarthritis: a cross-sectional study

OBJECTIVE

To investigate knee contact forces (KCFs), and their relationships with knee pain, across grades of radiographic knee osteoarthritis (OA) severity.

DESIGN

Cross-sectional exploratory analysis of 164 participants with medial knee OA. Radiographic severity was classified as mild (grade 2), moderate (grade 3) or severe (grade 4) using the Kellgren & Lawrence (KL) scale. Walking knee pain was assessed using an 11-point numerical rating scale. External knee adduction moment (external KAM) and internal muscle forces were used to calculate medial, lateral and total KCFs using a musculoskeletal computational model. Force-time series across stance phase of gait were compared across KL grades using Statistical Parametric Mapping. Associations between KCFs and pain across KL grades were assessed using linear models.

RESULTS

Medial KCFs during early and middle stance were higher in participants with KL3 and KL4 compared to those with KL2. In contrast, lateral KCFs were higher in those with KL2 compared to KL3 and KL4 in middle to late stance. The external loading component (i.e., KAM) of the medial KCF during middle to late stance was also greater in participants with KL3 and KL4 compared to those with KL2, whereas the internal (i.e., muscle) component was greater in those with KL3 and KL4 compared to KL3 during early stance. There were no associations between medial KCF and knee pain in any KL grade.

CONCLUSIONS

Medial and lateral KCFs differ between mild, moderate and severe radiographic knee OA but are not associated with knee pain severity for any radiographic OA grade.

Differentiating border-zone tissue from post-infarct scar using ripple mapping during VT ablation

Funding Acknowledgements

Type of funding sources: None.

Background

Areas of post-infarct ventricular scar and border-zone slow conduction are often highlighted on a bipolar voltage map with generalized values 0.5mV–1.5mV. The true voltage that differentiates regions of conducting from non-conducting tissue is unknown. Ripple Mapping (RM)displays allows conducting tissue to be seen as areas supporting Ripple activation, and non-conducting tissue as areas devoid of Ripple activation.

Purpose

We describe application of Ripple Maps to differentiate areas of scar from conducting tissue during ischemic VT ablation.

Methods

Dense bipolar voltage maps were created (Pentaray catheter, pacing 80-100bpm) and presented as a single value (e.g. 0.5mV-0.5mV) to binarize the color display (red and purple). RMs were superimposed on the voltage map and played above a pre-set noise threshold (&gt;0.05mV). The voltage map mV limit was sequentially reduced ("border-zone threshold") until only those areas devoid of Ripple bars appeared red. The surrounding border-zone supporting ripple activation thus appeared purple. We performed off-line analysis of border-zone voltage thresholds from a series of RM guided VT ablations.

Results

10 consecutive patients (LVEF 32.3±7.5%) with remote myocardial infarction underwent VT ablation (median 19days (IQR 8-33) since last VT). Bipolar voltage mapping (5873±2841 points, median shell area 224cm2), revealed voltages&lt;0.5mV covered a median 11% (IQR 7-17%) of the shell. The border-zone voltage threshold was median 0.2mV (range 0.12mV - 0.3mV). Non-conducting tissue below this value covered only median 5% (IQR 3-7%) of the entire shell. VT was mappable in 4 patients, and the isthmus was bordered by tissue below the same border-zone threshold as found in normal rhythm. The border-zone was homogenized with ablation(40-50W, median 29 mins (IQR 22-33), and clinical VT was non-inducible in all, and 9 pts (91%) remain sustained VT-free at median 90-day follow-up (IQR 23-139), 2-weeks blanking period).

Picture 1 presents an infero-lateral LV infarct collected in an RV paced rhythm (7340points) and displayed at conventional bipolar voltage settings 0.5-1.5mV. Tissue with voltages&lt;0.5mV appear red and cover 30% of the total area. In this case, this border-zone voltage threshold was defined as 0.25mV. Non-conducting tissue, seen as areas devoid of ripple bars below this value, now appeared as red, and covered only 11% of the total area. Picture 2 demonstrates the morphologies of 4 poorly tolerated induced VTs during this case. Each had near perfect pacemaps to the exit sites of border-zone tissue defined using this approach, and were targets for ablation resulting in complete non-inducibility and no VT recurrence in early follow-up.

Conclusion

The bipolar voltage that differentiates putative scar from bordering conducting tissue is unique to each patient, and far lower than 0.5mV-1.5mV. RM presents a practical approach to visualize the border-zone activation to guide ablation.

How does hip osteoarthritis differ from knee osteoarthritis?

Hip and knee osteoarthritis (OA) are leading causes of global disability. Most research to date has focused on the knee, with results often extrapolated to the hip, and this extends to treatment recommendations in clinical guidelines. Extrapolating results from research on knee OA may limit our understanding of disease characteristics specific to hip OA, thereby constraining development and implementation of effective treatments. This review highlights differences between hip and knee OA with respect to prevalence, prognosis, epigenetics, pathophysiology, anatomical and biomechanical factors, clinical presentation, pain and non-surgical treatment recommendations and management.

Maintenance therapy of patients with recurrent epithelial ovarian carcinoma with the anti-tumor-associated-mucin-1 antibody gatipotuzumab: results from a double-blind, placebo-controlled, randomized, phase II study

BACKGROUND

Gatipotuzumab is a humanized monoclonal antibody recognizing the carbohydrate-induced epitope of the tumor-associated mucin-1 (TA-MUC1). This study aimed to evaluate the efficacy and safety of switch maintenance therapy with gatipotuzumab in patients with TA-MUC1-positive recurrent ovarian, fallopian tube, or primary high-grade serous peritoneal cancer.

PATIENTS AND METHODS

In this double-blind, randomized, placebo-controlled, phase II trial, patients with at least stable disease (SD) following chemotherapy were randomized 2:1 to receive intravenous gatipotuzumab (500 mg followed by 1700 mg 1 week later) or placebo every 3 weeks until tumor progression or unacceptable toxicity occurred. Stratification factors were the number of prior chemotherapy lines (2 versus 3-5), response versus SD after the most recent chemotherapy, and progression-free survival (PFS) <6 versus 6-12 months following the prior therapy. Primary endpoint was PFS according to modified immune-related RECIST 1.1 response criteria. Secondary endpoints were PFS at 6 months, safety, overall response rate, CA-125 progression, overall survival, quality of life, and pharmacokinetics.

RESULTS

Overall, 216 patients were randomized to gatipotuzumab (n  =  151) or placebo (n  =  65). Median PFS with gatipotuzumab was 3.5 months as compared with 3.5 months with placebo (hazard ratio 0.96, 95% confidence interval 0.69-1.33, P  =  0.80). No advantage for gatipotuzumab over placebo was seen in the secondary efficacy endpoints or in any stratified subgroups. Gatipotuzumab was well tolerated, with mild to moderate infusion-related reactions being the most common adverse events.

CONCLUSIONS

Gatipotuzumab switch maintenance therapy does not improve outcome in TA-MUC1-positive ovarian cancer patients.

TRIAL REGISTRATION

ClinicalTrials.govNCT01899599; https://clinicaltrials.gov/ct2/show/NCT01899599.

Exploring older adults' experiences using technology during a viral pandemic

Background

Older adults are at greater risk for morbidity and mortality associated with COVID‐19. Spatial distancing and sequestering practices are recommended to limit viral exposure. Older adults adopting these practices are at increased risk of social isolation and adverse health outcomes. Remote technologies offer various platforms for satisfying socialization and healthcare needs while sequestering. Understanding how older adults are using technology has implications for wellbeing during a pandemic.

Method

Researchers attempted to contact all participants enrolled in the University of Kentucky Alzheimer's Disease Research Center longitudinal study via telephone to survey technology use (n = 706). Participants were contacted directly, except for demented participants, whose primary caregivers were contacted to respond on their behalf, when possible. Participants and caregivers gave their assent verbally to complete the voluntary survey, the procedures of which were approved by the IRB. The surveys consisted of validated instruments to gauge the extent of use of and comfort with technology. Spearman correlations, chi‐square tests, and t‐tests were used to explore data.

Result

Ultimately, 384 participants were reached and 332 consented to participate. Most reported reliable home internet access (91.5%) and some internet use (90.6%). Recent feelings of loneliness were not related to any technology‐related variables (all ps > 0.29) other than decreasing with greater willingness to use telehealth (Rho = ‐0.11, p = 0.06). Those who reported a lack of comfort with technology (n = 76) were less likely to text messaging (67% vs 78%) and social media (56% vs 69%), ps ≤ 0.06, but felt socially connected using technology at similar levels (82% vs 75%), p = 0.22. Nearly 70% of this group reported they would use technology more with training. Across all participants, willingness to use telehealth was not related to frequency of frustration with tech (Rho = 0, p = 0.99).

Conclusion

The results suggest that some older adults’ use of technology is limited by familiarity. Lack of familiarity does not appear to create a barrier to using telehealth nor does frustration with technology appear to limit telehealth use. The findings have implications for supporting older adults sequestered during a pandemic but potentially more broadly.

Association of multimorbidity and changes in health-related quality of life following myocardial infarction: a UK multicentre longitudinal patient-reported outcomes study

BACKGROUND

Multimorbidity is prevalent for people with myocardial infarction (MI), yet previous studies investigated single-health conditions in isolation. We identified patterns of multimorbidity in MI survivors and their associations with changes in HRQoL.

METHODS

In this national longitudinal cohort study, we analysed data from 9566 admissions with MI from 77 National Health Service hospitals in England between 2011 and 2015. HRQoL was measured using EuroQol 5 dimension (EQ5D) instrument and visual analogue scale (EQVAS) at hospitalisation, 6, and 12 months following MI. Latent class analysis (LCA) of pre-existing long-term health conditions at baseline was used to identify clusters of multimorbidity and associations with changes in HRQoL quantified using mixed effects regression analysis.

RESULTS

Of 9566 admissions with MI (mean age of 64.1 years [SD 11.9], 7154 [75%] men), over half (5119 [53.5%] had multimorbidities. LCA identified 3 multimorbidity clusters which were severe multimorbidity (591; 6.5%) with low HRQoL at baseline (EQVAS 59.39 and EQ5D 0.62) which did not improve significantly at 6 months (EQVAS 59.92, EQ5D 0.60); moderate multimorbidity (4301; 47.6%) with medium HRQoL at baseline (EQVAS 63.08, EQ5D 0.71) and who improved at 6 months (EQVAS 71.38, EQ5D 0.76); and mild multimorbidity (4147, 45.9%) at baseline (EQVAS 64.57, EQ5D 0.75) and improved at 6 months (EQVAS 76.39, EQ5D 0.82). Patients in the severe and moderate groups were more likely to be older, women, and presented with NSTEMI. Compared with the mild group, increased multimorbidity was associated with lower EQ-VAS scores (adjusted coefficient: -5.12 [95% CI -7.04 to -3.19] and -0.98 [-1.93 to -0.04] for severe and moderate multimorbidity, respectively. The severe class was more likely than the mild class to report problems in mobility, OR 9.62 (95% confidence interval: 6.44 to 14.36), self-care 7.87 (4.78 to 12.97), activities 2.41 (1.79 to 3.26), pain 2.04 (1.50 to 2.77), and anxiety/depression 1.97 (1.42 to 2.74).

CONCLUSIONS

Among MI survivors, multimorbidity clustered into three distinct patterns and was inversely associated with HRQoL. The identified multimorbidity patterns and HRQoL domains that are mostly affected may help to identify patients at risk of poor HRQoL for which clinical interventions could be beneficial to improve the HRQoL of MI survivors.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01808027 and NCT01819103.