The incremental yield of prenatal exome sequencing over chromosome microarray for congenital heart abnormalities: A systematic review and meta-analysis

OBJECTIVES

To determine the incremental yield of prenatal exome sequencing (PES) over standard testing in fetuses with an isolated congenital heart abnormality (CHA), CHA associated with extra-cardiac malformations (ECMs) and CHA dependent upon anatomical subclassification.

METHODS

A systematic review of the literature was performed using MEDLINE, EMBASE, Web of Science and grey literature January 2010-February 2023. Studies were selected if they included greater than 20 cases of prenatally diagnosed CHA when standard testing (QF-PCR/chromosome microarray/karyotype) was negative. Pooled incremental yield was determined. PROSPERO CRD 42022364747.

RESULTS

Overall, 21 studies, incorporating 1957 cases were included. The incremental yield of PES (causative pathogenic and likely pathogenic variants) over standard testing was 17.4% (95% CI, 13.5%-21.6%), 9.3% (95% CI, 6.6%-12.3%) and 35.9% (95% CI, 21.0%-52.3%) for all CHAs, isolated CHAs and CHAs associated with ECMs. The subgroup with the greatest yield was complex lesions/heterotaxy; 35.2% (95% CI 9.7%-65.3%). The most common syndrome was Kabuki syndrome (31/256, 12.1%) and most pathogenic variants occurred de novo and in autosomal dominant (monoallelic) disease causing genes (114/224, 50.9%).

CONCLUSION

The likelihood of a monogenic aetiology in fetuses with multi-system CHAs is high. Clinicians must consider the clinical utility of offering PES in selected isolated cardiac lesions.

Evaluation of therapeutic radiographer contouring for magnetic resonance image guided online adaptive prostate radiotherapy

BACKGROUND AND PURPOSE

The implementation of MRI-guided online adaptive radiotherapy has facilitated the extension of therapeutic radiographers' roles to include contouring, thus releasing the clinician from attending daily treatment. Following undergoing a specifically designed training programme, an online interobserver variability study was performed.

MATERIALS AND METHODS

117 images from six patients treated on a MR Linac were contoured online by either radiographer or clinician and the same images contoured offline by the alternate profession. Dice similarity coefficient (DSC), mean distance to agreement (MDA), Hausdorff distance (HD) and volume metrics were used to analyse contours. Additionally, the online radiographer contours and optimised plans (n = 59) were analysed using the offline clinician defined contours. After clinical implementation of radiographer contouring, target volume comparison and dose analysis was performed on 20 contours from five patients.

RESULTS

Comparison of the radiographers' and clinicians' contours resulted in a median (range) DSC of 0.92 (0.86 - 0.99), median (range) MDA of 0.98 mm (0.2-1.7) and median (range) HD of 6.3 mm (2.5-11.5) for all 117 fractions. There was no significant difference in volume size between the two groups. Of the 59 plans created with radiographer online contours and overlaid with clinicians' offline contours, 39 met mandatory dose constraints and 12 were acceptable because 95 % of the high dose PTV was covered by 95 % dose, or the high dose PTV was within 3 % of online plan. A clinician blindly reviewed the eight remaining fractions and, using trial quality assurance metrics, deemed all to be acceptable. Following clinical implementation of radiographer contouring, the median (range) DSC of CTV was 0.93 (0.88-1.0), median (range) MDA was 0.8 mm (0.04-1.18) and HD was 5.15 mm (2.09-8.54) respectively. Of the 20 plans created using radiographer online contours overlaid with clinicians' offline contours, 18 met the dosimetric success criteria, the remaining 2 were deemed acceptable by a clinician.

CONCLUSION

Radiographer and clinician prostate and seminal vesicle contours on MRI for an online adaptive workflow are comparable and produce clinically acceptable plans. Radiographer contouring for prostate treatment on a MR-linac can be effectively introduced with appropriate training and evaluation. A DSC threshold for target structures could be implemented to streamline future training.

Interobserver variation of clinical oncologists compared to therapeutic radiographers (RTT) prostate contours on T2 weighted MRI

The implementation of MRI-guided online adaptive radiotherapy has enabled extension of therapeutic radiographers' roles to include contouring. An offline interobserver variability study compared five radiographers' and five clinicians' contours on 10 MRIs acquired on a MR-Linac from 10 patients. All contours were compared to a "gold standard" created from an average of clinicians' contours. The median (range) DSC of radiographers' and clinicians' contours compared to the "gold standard" was 0.91 (0.86-0.96), and 0.93 (0.88-0.97) respectively illustrating non-inferiority of the radiographers' contours to the clinicians. There was no significant difference in HD, MDA or volume size between the groups.

Perfluorooctanoic Acid Transport in Soil and Absorption and Distribution in Alfalfa (Medicago sativa)

ABSTRACT

Perfluorooctanoic acid (PFOA) is used as a surfactant in consumer and industrial products and is frequently found in biosolids from wastewater treatment plants. When present in biosolids applied to croplands, PFOA can contaminate feed and fodder used by livestock, but the extent of PFOA transfer from soil to plants is not well characterized. A single dose of radiocarbon (14C)-tagged PFOA was applied to unplanted soil or soil containing growing alfalfa. PFOA transport through unplanted soil and uptake by alfalfa was monitored over a 10-week study period. Radiocarbon was initially measured in roots, stems, and leaves 7 days after [14C]-PFOA application to soil. PFOA accumulation was greatest in leaves during the 10-week sampling. By week 10, PFOA migration through unplanted soil had reached a depth of 22.8 ± 2.5 cm. In contrast, PFOA migrated to 7.5 ± 2.5 cm in soil containing alfalfa plants. The greatest predictor of PFOA concentration in alfalfa leaves was PFOA concentration in the top 5 cm of soil; PFOA concentrations at lower depths were not correlated with alfalfa PFOA concentrations. PFOA transport through soil may be slowed by the presence of forage; however, PFOA accumulation in edible portions of forage plants may increase food animal exposure to PFOA residues.

HIGHLIGHTS

Investigating spatial fractionation and radiation induced bystander effects: a mathematical modelling approach

Radiation induced bystander effects (RIBEs) have been shown to cause death in cells receiving little or no physical dose. In standard radiotherapy, where uniform fields are delivered and all cells are directly exposed to radiation, this phenomenon can be neglected. However, the role of RIBEs may become more influential when heterogeneous fields are considered. Mathematical modelling can be used to determine how these heterogeneous fields might influence cell survival, but most established techniques account only for the direct effects of radiation. To gain a full appreciation of how non-uniform fields impact cell survival, it is also necessary to consider the indirect effects of radiation. In this work, we utilise a mathematical model that accounts for both the direct effects of radiation on cells and RIBEs. This model is used to investigate how spatially fractionated radiotherapy plans impact cell survivalin vitro. These predictions were compared to survival in normal and cancerous cells following exposure to spatially fractionated plans using a clinical linac. The model is also used to explore how spatially fractionated radiotherapy will impact tumour controlin vivo. Results suggest that spatially fractionated plans are associated with higher equivalent uniform doses than conventional uniform plans at clinically relevant doses. The model predicted only small changes changes in normal tissue complication probability, compared to the larger protection seen clinically. This contradicts a central paradigm of radiotherapy where uniform fields are assumed to maximise cell kill and may be important for future radiotherapy optimisation.

The Baby Hearts Study - a case-control methodology with data linkage to evaluate risk and protective factors for congenital heart disease

Introduction

The Baby Hearts study aimed to investigate risk and protective factors for congenital heart disease (CHD), and to investigate the health behaviours of a representative sample of pregnant women in Northern Ireland.

Objectives

We describe and evaluate the population-based case-control design enhanced with data linkage to administrative health data.

Methods

Cases (mothers of babies with CHD, n=286) were recruited following diagnosis prenatally or postnatally. Controls (mothers of babies without CHD, n=966) were recruited at 18-22 weeks gestation, from all women attending each maternity unit during a designated month. Hybrid data collection methods were used, including a self-administered iPad/postal questionnaire, and linkage to maternity and prescription records.

Results

Refusal rates were low (8%). iPad questionnaire completion at clinic or home visit had high acceptability whereas postal questionnaires were poorly returned leading to a further 9-10% loss of eligible cases/controls. In total, 61% of eligible cases and 68% of eligible controls were recruited, closely representative of the Northern Ireland population, with no evidence of selection bias. Of those recruited, 97% gave consent for linkage to medical records. Thirty-three percent of women had an unplanned pregnancy and 76% suspected they were pregnant by 5 weeks gestation, with no significant differences between cases and controls. There was considerable discordance between self-report, maternity and prescription records regarding medications obtained/taken in the first trimester, but no evidence of differences between cases and controls that would indicate substantial recall bias. Although there was high concordance between self-report and maternity records regarding folic acid supplementation, cases had significantly lower concordance than controls.

Conclusions

Our results suggest hybrid data collection approaches are a useful way forward for aetiological studies to reduce responder burden and address and estimate recall bias, and that the Baby Hearts study protocol is suitable for replication in other populations, modified to the local context.

Supporting families of critically ill children at home using videoconferencing

Home videoconferencing links for families of children recently discharged with complex congenital heart disease may be useful in monitoring potentially unstable patients. A randomized controlled trial was carried out comparing home videoconferencing with telephone contact. Patients were randomized to an interventional videoconferencing group (n= 14), or to one of two control groups: the first (n = 9) received the same ad hoc telephone support that was available to all patients; the second group (n = 1 3) received regular telephone calls with the same protocol as those in the videoconferencing group. The results from the trial are still being analysed. Our experience with commercial cable modem transmission quickly showed that this is an unsuitable modality. Preliminary results with ISDN videoconferencing are encouraging. Initial results and feedback from families strongly suggest that videoconferencing provides significant benefits over telephone follow-up.

Impact of a regional training program in fetal echocardiography for sonographers on the antenatal detection of major congenital heart disease

OBJECTIVES

The aims of this study were to ascertain the effect of a regional training program in fetal echocardiography for obstetric radiographers on the antenatal detection of major congenital heart disease (CHD) and to document short-term outcomes for major CHD.

METHODS

All 87 obstetric radiographers in Northern Ireland were invited to attend 2.5 days of training during a 1-year period. Data were collected before and after the training, over a 5-year study period, to assess the effect of training on the antenatal detection of CHD in the population.

RESULTS

The antenatal detection of major CHD rose significantly, from 28% (72/262) pretraining to 43% (36/84) in the year of training (P = 0.008). Antenatal diagnosis of four-chamber-view defects rose significantly (from 38% to 54%; P = 0.04), as did detection of outflow-tract-view defects (from 8% to 21%; P = 0.05). Twelve per cent (13/108) of cases died spontaneously in utero and 8% (9/108) were terminated. Only 78% (67/86) of live-born cases in which CHD had been diagnosed antenatally survived the neonatal period, compared to 93% (221/238) with a postnatal diagnosis of CHD (P < 0.001).

CONCLUSIONS

Even with a relatively simple training program, significant improvements can be made in the antenatal detection of CHD. With training, obstetric sonographers can successfully assess outflow tracts. Antenatally diagnosed cases have more complex CHD and this probably contributes to poor neonatal survival.

A controlled trial of early interventions to promote maternal adjustment and development in infants born with severe congenital heart disease

Abstract Background Congenital heart disease can have a negative impact on both infant development and maternal adjustment. This study considered the impact of a new programme of early psychosocial interventions on such outcomes, following the birth of a child with severe congenital heart disease. Methods Seventy infants and their mothers were assigned to an intervention or control group based on order of presentation to the unit. Interventions aimed at bolstering mother-infant transactions, through psychoeducation, parent skills training and narrative therapy techniques were implemented. Results Clinically and statistically significant gains were observed at 6-month follow-up on the mental (but not the psychomotor) scale of the Bayleys-II. Positive gains were also manifested on feeding practices, maternal anxiety, worry and appraisal of their situation. Conclusions A programme of generalizable psychosocial interventions is shown to have a positive impact on the infant with severe congenital heart disease and the mother.

Assisting the transition from hospital to home for children with major congenital heart disease by telemedicine: a feasibility study and initial results

Parents of children hospitalized with major congenital heart disease often state that the weeks following discharge from hospital are particularly difficult. There is a sudden change from 24-h medical supervision and care to outpatient reviews. Videoconferencing not only gives the family an opportunity to have visual and audio contact with staff but also allows clinicians to visually assess the patient. We have investigated the feasibility of using videoconferencing to provide support for families at home. We also report the early results of a randomized control trial comparing videoconference support with regular telephone support and the current clinic review follow-up.

Assessing ASDs prior to device closure using 3D echocardiography. Just pretty pictures or a useful clinical tool?

AIMS

To determine the usefulness of three-dimensional transthoracic echocardiography (3D echo) in assessment of secundum atrial septal defects (ASDs) considered for device closure. To compare the findings from 3D echo with those from two-dimensional transoesophageal echocardiography (TOE) regarding dimensions, morphology and suitability for device closure.

METHODS AND RESULTS

Twenty-four patients were enrolled in this prospective, crossover study. Three-dimensional echo and TOE data were collected, analysed and compared, assessing quantitative data including maximum defect diameter, area and circumference. Qualitative morphology such as the presence of fenestrations and the defect margins were noted, and an assessment of the suitability for device closure was made using each modality. Eighteen (75%) of the 3D data sets produced usable data for analysis. In each case the maximum diameter of the defect was larger on 3D echo than on TOE (mean difference = 0.34 cm, P < 0.001). On three occasions suitability for device closure could not be determined using 3D echo. On the other 15 occasions there was agreement between the TOE and 3D echo data.

CONCLUSIONS

Three-dimensional echo provides comparable data with TOE when attempting to predict suitability for device closure without the need for general anaesthetic or sedation. It also provides useful additional dynamic and morphological information.

Determinants of neuropsychological and behavioural outcomes in early childhood survivors of congenital heart disease

AIMS

To evaluate the relative effect of cyanosis, surgical interventions and family processes on neuropsychological and behavioural outcomes in 4-year-old survivors of serious congenital heart disease (CHD).

METHODS

90 children with a range of cyanotic and acyanotic conditions, who underwent either corrective or palliative surgery, completed a neuropsychological and behavioural evaluation. Families of participants were also profiled by evaluation of maternal mental health, worry, social support, parenting style and family functioning.

RESULTS

Compromised neuropsychological outcomes were associated with a combination of cyanotic conditions and open-heart surgery, but this was not exacerbated by having a complex, palliative, status. Both cyanotic and acyanotic conditions were associated with specific sensorimotor delays, regardless of method of the correction. Only children with complex conditions and palliative interventions seemed at risk of poor behavioural outcomes; indeed, children with cyanosis with complete repair showed favourable behavioural outcomes compared with controls. Multivariate analyses highlighted the sometimes greater relevance of family processes (eg parenting style, maternal mental health and worry), rather than disease or surgical factors, in predicting especially behavioural outcomes.

CONCLUSIONS

The findings (1) suggest a more complex relationship between cyanosis, surgical methods of correction, neuropsychological and behavioural outcomes than previously charted, (2) highlight that family processes may be aetiologically more important than disease and surgical factors, and (3) indicate specific targets for secondary prevention programmes for this at-risk population.

Miliary neonatal hemangiomatosis with fulminant heart failure and cardiac septal hypertrophy in two infants

Miliary neonatal hemangiomatosis is a rare, life-threatening condition associated with cutaneous and multiorgan involvement. We report two infants with this condition who had fulminant cardiac failure and cardiac septal hypertrophy. The first was a 5-day-old boy who presented with increasing numbers of cutaneous hemangiomata associated with worsening cardiac failure. Magnetic resonance imaging (MRI) showed extensive hepatic hemangioma. Despite treatment with systemic corticosteroids and subcutaneous interferon alfa-2b his disease progressed. Hepatic artery embolization was unsuccessful. The infant died of congestive cardiac failure at 6 weeks of age. Postmortem examination showed a massively enlarged cardiac interventricular septum and biventricular hypertrophy. The second patient was a 1-week-old girl who also had cutaneous hemangioma and cardiac decompensation. MRI showed extensive intrahepatic involvement. She was treated early with corticosteroids and interferon alpha, which resulted in involution of the cutaneous and hepatic lesions. Cardiac septal hypertrophy did not persist at late follow-up, and the association of miliary neonatal hemangiomatosis and cardiac septal hypertrophy has not yet been established.

Tricuspid valvar endocarditis caused by penicillin resistant pneumococcus

A 6-year-old boy presented with endocarditis of the tricuspid valve caused by penicillin resistant pneumococcus. He had no history of congenital cardiac disease. The likely portal of entry for the organism was the middle ear.

Application of a low cost telemedicine link to the diagnosis of neonatal congenital heart defects by remote consultation

OBJECTIVE

To determine whether accurate remote echocardiographic diagnosis of congenital heart disease could be achieved using a low cost telemedicine system.

DESIGN

Echocardiographic images obtained by a paediatrician from neonates suspected of having congenital heart disease were transmitted by a telemedicine link across two integrated service digital network (ISDN) lines to a regional paediatric cardiology unit for interpretation by a consultant paediatric cardiologist. The "tele-echo" diagnosis was verified by the paediatric cardiologist on direct consultation and echocardiography.

SETTING

Neonatal unit of Altnagelvin Hospital, Londonderry (a district general hospital) and the regional paediatric cardiology department, Royal Belfast Hospital for Sick Children.

MAIN OUTCOME MEASURES

Accuracy of the diagnosis made using the telemedicine link; impact on patient management.

RESULTS

Between September 1995 and September 1997 echocardiographic images were transmitted on 63 patients. A diagnosis was made in 61 (97%) (transmitted images were unsatisfactory in two). Congenital heart disease was diagnosed in 42 patients. Fourteen patients with major congenital heart disease were accurately diagnosed within 24 hours of admission using the telemedicine link and were transferred to the regional paediatric cardiology unit. A further 28 with less serious congenital heart disease continued to be managed at the district general hospital. Congenital heart disease was excluded in 19. Follow up consultation confirmed accurate diagnosis or exclusion of congenital heart disease in 57 (93%). There were four inaccurate diagnoses (6.3%; three undetected small ventricular septal defects and one pulmonary stenosis).

CONCLUSIONS

Transmitted images were of sufficient quality to allow confirmation or exclusion of major congenital heart disease. The telemedicine link facilitated early diagnosis and initiation of appropriate management in patients with complex congenital heart disease and avoided the need for transfer in those where significant congenital heart disease was excluded.

Value of a low-cost telemedicine link in the remote echocardiographic diagnosis of congenital heart defects

We established a low-cost telemedicine link from a district general hospital to the regional paediatric cardiology department about 120 km away. The link was used to transmit echocardiographic images of newborn infants suspected of having congenital heart disease (CHD) to the referral centre, with simultaneous video and audio contact for consultation. Echocardiograms were transmitted for 61 patients suspected of having CHD, aged from 1 to 42 days. The transmitted images were of adequate quality for the paediatric cardiologist to make a diagnosis in 59 (97%). Congenital heart abnormalities were diagnosed in 38 (64%). Twelve patients (20%) had major CHD diagnosed on the transmitted scan and required transfer to the regional cardiology unit either urgently or electively after initial measures to stabilize the patient. Our findings suggest that, for babies suspected of having CHD, ultrasound images of diagnostic quality can be obtained and transmitted using a low-cost telemedicine system.

Diagnosis of neonatal congenital heart defects by remote consultation using a low-cost telemedicine link

To determine whether telemedicine could assist in the earlier diagnosis of neonates with congenital heart disease (CHD) in an area hospital remote from a paediatric cardiologist, we established a low-cost telemedicine link between the neonatal unit of a district general hospital and the regional paediatric cardiology unit. Realtime ultrasound images of babies suspected of having CHD were obtained by a paediatrician and transmitted for realtime interpretation by a paediatric cardiologist. In a four-month pilot study, 10 neonates were studied in this way. In eight of the ten cases, the diagnosis made over the telemedicine link was confirmed subsequently in a direct examination at the regional unit. In one case the patient died before the direct examination was possible. In one case two small muscular ventricular septal defects were missed on the remote examination. Our early experience suggests that, with realtime guidance by a paediatric cardiologist, transmitted images of sufficient quality to allow confirmation or exclusion of major cardiac defects can be obtained. This form of remote consultation should improve morbidity and mortality rates by reducing the waiting time for specialist diagnosis and treatment.

Cleft lip and palate, hypertelorism, brachycephaly, flat facial profile, and congenital heart disease in three brothers

A "new" syndrome was identified by McPherson and Clemens [1996: Am J Med Genet 62:58-60] in a brother and sister with bilateral cleft lip and palate, hypertelorism, flat facial profile, flat occiput, and complex heart defects. The brother also had a bilobed tongue and the sister had malrotation of the intestine and bifid thumbs. We describe three brothers with similar anomalies apart from the bilobed tongue, malrotation of the intestine, and bifid thumbs. McPherson and Clemens [1996: Am J Med Genet 62:58-60] suggested autosomal recessive inheritance. Our observation of three affected brothers also raises the possibility of X-linked recessive inheritance.

Pseudoinfarction pattern in an infant

A 4-week-old female infant presented with congestive heart failure, moderate mitral regurgitation, and an electrocardiographic pattern of anterolateral myocardial infarction. Angiography revealed normal coronary arteries and moderate mitral regurgitation. A single-catheter electrophysiology study confirmed the presence of an accessory atrioventricular conduction pathway.

Kawasaki disease--the Northern Ireland experience

In the period 1985-1991 inclusive, forty five cases of Kawasaki Disease were identified in Northern Ireland. The number of cases increased each year until 1988 when the incidence was 19 per million population under 16 years, the highest reported for any region in the United Kingdom (data from British Paediatric Surveillance Unit). A high incidence of cardiac involvement was found, with 18(40%) having proximal coronary artery dilatation or aneurysm. and 8(17.7%) with pericardial effusion detected by 2D Echocardiography during or shortly after the acute illness. One year after disease onset, persistent coronary artery changes were detectable by 2D Echocardiography in 53% of those initially affected. There have been no deaths and no patient has so far developed myocardial infarction. One patient has required coronary artery bypass grafting. A protocol for the acute management and long term follow-up of Kawasaki Disease is suggested.

Breast cancer workshop for nurses: innovative approach to staff development

Breast cancer is a major health problem today. Mastectomy and adjuvant therapy are standard treatments available in most acute care hospitals. Nurses who care for mastectomy patients have primary responsibility for patient education. This article describes use of a breast cancer workshop to strengthen teaching capabilities of staff nurses. The workshop addresses facts regarding breast cancer and the educational needs of breast cancer patients. It also provides opportunity for nurses to develop patient education standards for patients who have had a mastectomy.