Outreach, Screening, and Randomization of APOE ε4 Carriers into an Alzheimer's Prevention Trial: A global Perspective from the API Generation Program

BACKGROUND

Alzheimer's disease (AD) prevention trials require a large outreach and screening funnel to identify cognitively unimpaired adults who meet the study's inclusion criteria, such as certain clinical or demographic criteria, genetic risk factors, and/or biomarker evidence of the disease.

OBJECTIVES

Describe tactics and strategies to identify and enroll cognitively unimpaired adults with one (heterozygotes [HT]) or two (homozygotes [HM]) copies of the APOE ε4 allele, a genetic risk factor for dementia due to AD, into the Alzheimer's Prevention Initiative (API) Generation Program, the largest and only prevention trials for late onset AD using this enrichment technique.

DESIGN AND SETTING

The Generation Program was comprised of two global, randomized, double-blind, placebo-controlled, parallel group adaptive design with variable treatment duration clinical trials. Generation Study 1 randomized participants into one of two cohorts: Cohort 1 which evaluated CAD106 vs. placebo or Cohort 2 which evaluated umibecestat vs placebo. Generation Study 2 randomized participants into two doses of umibecestat vs. placebo. The Generation Program was terminated early in 2019, while enrollment was still occurring.

PARTICIPANTS

Both Generation Study 1 and Generation Study 2 enrolled cognitively unimpaired APOE ε4 HMs aged 60-75; Generation Study 2 also enrolled APOE ε4 HTs ages 60-75 with elevated brain amyloid.

METHODS AND MEASUREMENTS

Describe results of the centralized and localized outreach, recruitment, screening strategies and tactics as well as characteristics of sites successful at enrolling genetically eligible participants, with a particular focus on APOE ε4 HMs given the 2-3% prevalence of this genotype.

RESULTS

At the time the trial program was terminated, 35,333 individuals had consented to the optional prescreening ICF1a/ICFA and provided a sample of DNA for APOE genotyping, 1,138 APOE ε4 HMs consented to screening for Generation Study 1 (ICF1b), and 1,626 APOE ε4 carriers were randomized into either Generation Study 1 or Generation Study 2. Genetic testing registries, partnerships with genetic testing/counseling companies, and the optional prescreening ICF1a/ICFA were the most successful strategies for identifying genetically eligible participants for screening.

CONCLUSIONS

It is feasible to recruit, screen and randomize cognitively unimpaired APOE ε4 carriers, particularly APOE ε4 HMs for a global AD prevention trial. The Generation Program was on track to complete enrollment by end of 2019. Factors that were key to this success included: working with sites to develop customizable outreach, recruitment, and screening programs specific to their site needs, providing forums for sites to exchange best practices, and developing partnerships between the sponsor team and trial sites.

Feeding preterm infants with breast milk – the role of maternal pressure

Background

Motheŕs own milk (MOM) is the best nutrition for preterm infants because of its preventive effects. Nevertheless, current research shows that mothers have problems getting into continuous lactation, especially after preterm birth. Breastfeeding-related pressure after prematurity has not been measured yet. It's relevance for the lactation is thus unclear, as well as the role of the NICU staff's attitudes. The aim of this study is to gain more knowledge about breastfeeding-related pressure in order to enable mothers to have a positive breastfeeding experience and to sensitise NICU staff about this topic.

Methods

The written survey included mothers of preterm infants with a birth weight under 1500g and an age from 6 to 24 months at the time of the survey. Descriptive and bivariate testing was used for analyses.

Results

Data of 506 mothers was included (32% response rate). One third totally agreed to perceive pressure regarding breastfeeding their child with MOM (36%). A milk volume over 500ml/day 14 days post-partum was reported in 60%. That the nutrition with MOM was promoted by the physicians in the NICU was totally agreed by 44% of the mothers. To the promotion by nurses, 50% totally agreed. Pearson Chi2-Test showed a significant correlation between milk volume and breastfeeding-related pressure (p = 0.005). Spearman’s correlation test showed a significant correlation between a high promotion of MOM by physicians (Spearman’s rho: -0.1150, p = 0.0109) and nurses (Spearman’s rho: -0.0949, p = 0.0362) and lower breastfeeding-related pressure.

Conclusions

Our findings indicate that breastfeeding-related pressure seems to affect most of the mothers of preterm infants and correlates with lactation, even if no direction of effect can be stated. A more breastfeeding promoting NICU staff is related to lower breastfeeding-related pressure. Therefore, NICU staff should be sensitised to breastfeeding-related pressure with regard to communication with mothers.

Key messages

• Noticing breastfeeding-related pressure as an important factor for mothers within their lactation process may have the potential to enhance mothers to achieve their breastfeeding goals.

• NICU staff should be aware of breastfeeding-related pressure to enable more mothers to have a positive breastfeeding experience.

[A pregnant woman with gastric cancer and placental involvement]

BACKGROUND

About 200 pregnant women in the Netherlands are yearly diagnosed with cancer. Pregnant women with cancer are often diagnosed later than non-pregnant women because symptoms of cancer are common during pregnancy and may elude suspicion. We report a patient with gastric carcinoma masquerading as hyperemesis gravidarum.

CASE DESCRIPTION

A 39-year-old pregnant woman was admitted at 25 weeks' gestation for the evaluation of persistent nausea, vomiting and weight loss (29 kg) since the beginning of her pregnancy. A presumptive diagnosis of hyperemesis gravidarum was made. Endoscopic examination was not performed. At 28 weeks' gestation caesarean was performed due to fetal distress and revealed a gastric tumour with abnormalities of the omentum. Microscopic examination of the omentum and placental specimen demonstrated poorly differentiated adenocarcinoma cells.

CONCLUSION

This case illustrates that endoscopic examination should be conducted in pregnant patients presenting with persistent gastrointestinal symptoms for the differential diagnosis of hyperemesis gravidarum.

Pregnancy in women with liver cirrhosis is associated with increased risk for complications: A systematic review and meta-analysis of the literature

BACKGROUND

Pregnancy and liver cirrhosis is a rare but increasing combination. Liver cirrhosis can raise the chance of maternal and fetal mortality and morbidity, although the exact risks remain unclear.

OBJECTIVE

To provide a systematic literature review and meta-analysis on maternal, fetal and obstetric complications among pregnant women with liver cirrhosis.

SEARCH STRATEGY

We performed a systematic literature search in the databases PubMed/MEDLINE and EMBASE (Ovid) from inception through 25 January 2021.

SELECTION CRITERIA

Studies including pregnancies with liver cirrhosis and controls were eligible.

DATA COLLECTION AND ANALYSIS

Two reviewers independently evaluated study eligibility. We used the random effects model for meta-analysis.

MAIN RESULTS

Our search yielded 3118 unique papers. We included 11 studies, including 2912 pregnancies in women with cirrhosis from 1982-2020. Seven studies were eligible for inclusion in the meta-analysis. The overall maternal mortality rate was 0.89%. Maternal mortality and variceal haemorrhage were lower in recent than in older studies. Most cases of maternal mortality due to variceal haemorrhage (70%) occurred during vaginal delivery. Pregnant women with liver cirrhosis had a higher chance of preterm delivery (OR 6.7, 95% CI 5.1-9.1), caesarean section (OR 2.6, 95% CI 1.7-3.9), pre-eclampsia (OR 3.8, 95% CI 2.2-6.5) and small-for-gestational-age neonates (OR 2.6, 95% CI 1.6-4.2) compared with the general obstetric population. Subgroup analyses could not be conducted.

CONCLUSIONS

Liver cirrhosis in pregnant women is associated with increases in maternal mortality and obstetric and fetal complications. Large international prospective studies are needed to identify risk factors for unfavourable outcome.

Heterozygosity testing and multiplex DNA panel screening as a potential tool to monitor health and inbreeding in a small, closed dog population

Background

Selective breeding in populations with a limited effective population size may result in a loss of genetic diversity, which can cause an increased concentration of specific disease liability genes. The Dutch Shepherd Dog (DSD) in the Netherlands is an example of such a breed with a small effective population.

Objective

To evaluate the measurement of genetic diversity and multiplex DNA panel screening for implementation in a breeding strategy for the Dutch Shepherd Dog (DSD) and to investigate the clinical relevance of potentially identified mutations in the multiplex DNA panel screening.

Results

Genome-wide SNP testing showed genetic isolation and reduced genetic diversity within coat variety subgroups of the DSD. Panel screening identified a Von Willebrand's Disease type I mutation. Although decreased Von Willebrand's Factor proteins were significantly lower in DSDs carrying the VWD-I allele compared to the wildtype, clinical follow-up did not show a significant association between the clinical phenotype and VWD-I genotype.

Conclusions

Genetic relationship measurement within a breed population may be a useful tool to enable breeding strategies to conserve genetic diversity. Results from a disease panel screening need to be evaluated for clinical relevance before breed selection restrictions can be considered.

Natural conception: repeated predictions over time

STUDY QUESTION

How can we predict chances of natural conception at various time points in couples diagnosed with unexplained subfertility?

SUMMARY ANSWER

We developed a dynamic prediction model that can make repeated predictions over time for couples with unexplained subfertility that underwent a fertility workup at a fertility clinic.

WHAT IS KNOWN ALREADY

The most frequently used prediction model for natural conception (the 'Hunault model') estimates the probability of natural conception only once per couple, that is, after completion of the fertility workup. This model cannot be used for a second or third time for couples who wish to know their renewed chances after a certain period of expectant management.

STUDY DESIGN, SIZE, DURATION

A prospective cohort studying the long-term follow-up of subfertile couples included in 38 centres in the Netherlands between January 2002 and February 2004. Couples with bilateral tubal occlusion, anovulation or a total motile sperm count <1 × 10⁶ were excluded.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The primary endpoint was time to natural conception, leading to an ongoing pregnancy. Follow-up time was censored at the start of treatment or at the last date of contact. In developing the new dynamic prediction model, we used the same predictors as the Hunault model, i.e. female age, duration of subfertility, female subfertility being primary or secondary, sperm motility and referral status. The performance of the model was evaluated in terms of calibration and discrimination. Additionally, we assessed the utility of the model in terms of the variability of the calculated predictions.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the 4999 couples in the cohort, 1053 (21%) women reached a natural conception leading to an ongoing pregnancy within a mean follow-up of 8 months (5th and 95th percentile: 1-21). Our newly developed dynamic prediction model estimated the median probability of conceiving in the first year after the completion of the fertility workup at 27%. For couples not yet pregnant after half a year, after one year and after one and a half years of expectant management, the median probability of conceiving over the next year was estimated at 20, 15 and 13%, respectively. The model performed fair in an internal validation. The prediction ranges were sufficiently broad to aid in counselling couples for at least two years after their fertility workup.

LIMITATIONS, REASONS FOR CAUTION

The dynamic prediction model needs to be validated in an external population.

WIDER IMPLICATIONS OF THE FINDINGS

This dynamic prediction model allows reassessment of natural conception chances after various periods of unsuccessful expectant management. This gives valuable information to counsel couples with unexplained subfertility that are seen for a fertility workup.

STUDY FUNDING/COMPETING INTERESTS

This study was facilitated by grant 945/12/002 from ZonMW, The Netherlands Organization for Health Research and Development, The Hague, The Netherlands. No competing interests.

Measuring Sperm DNA Fragmentation and Clinical Outcomes of Medically Assisted Reproduction: A Systematic Review and Meta-Analysis

Sperm DNA fragmentation has been associated with reduced fertilization rates, embryo quality, pregnancy rates and increased miscarriage rates. Various methods exist to test sperm DNA fragmentation such as the sperm chromatin structure assay (SCSA), the sperm chromatin dispersion (SCD) test, the terminal deoxynucleotidyl transferase mediated deoxyuridine triphosphate nick end labelling (TUNEL) assay and the single cell gel electrophoresis (Comet) assay. We performed a systematic review and meta-analysis to assess the value of measuring sperm DNA fragmentation in predicting chance of ongoing pregnancy with IVF or ICSI. Out of 658 unique studies, 30 had extractable data and were thus included in the meta-analysis. Overall, the sperm DNA fragmentation tests had a reasonable to good sensitivity. A wide variety of other factors may also affect the IVF/ICSI outcome, reflected by limited to very low specificity. The constructed hierarchical summary receiver operating characteristic (HSROC) curve indicated a fair discriminatory capacity of the TUNEL assay (area under the curve (AUC) of 0.71; 95% CI 0.66 to 0.74) and Comet assay (AUC of 0.73; 95% CI 0.19 to 0.97). The SCSA and the SCD test had poor predictive capacity. Importantly, for the TUNEL assay, SCD test and Comet assay, meta-regression showed no differences in predictive value between IVF and ICSI. For the SCSA meta-regression indicated the predictive values for IVF and ICSI were different. The present review suggests that current sperm DNA fragmentation tests have limited capacity to predict the chance of pregnancy in the context of MAR. Furthermore, sperm DNA fragmentation tests have little or no difference in predictive value between IVF and ICSI. At this moment, there is insufficient evidence to recommend the routine use of sperm DNA fragmentation tests in couples undergoing MAR both for the prediction of pregnancy and for the choice of treatment. Given the significant limitations of the evidence and the methodological weakness and design of the included studies, we do urge for further research on the predictive value of sperm DNA fragmentation for the chance of pregnancy after MAR, also in comparison with other predictors of pregnancy after MAR.

IUI and IVF for unexplained subfertility: where did we go wrong?

IUI is a first-line treatment for couples with unexplained or mild male subfertility and has become one of the most widely used fertility-enhancing treatments. The results of a recent trial comparing IVF to IUI, demonstrating similar live birth rates, have been used to build a case supporting the effectiveness of IUI. Yet, this conclusion might be somewhat premature, as the superiority of neither IUI nor IVF over no treatment has ever been proven. The evidence on the effectiveness and safety of IUI and IVF has been evaluated in two Cochrane reviews which both suggested that there is insufficient evidence to conclude that IUI or IVF is effective compared to sexual intercourse in couples with unexplained subfertility. Recommendations for clinical practice have been given in the most recent National Institute for Health and Care Excellence fertility guideline that advises not to offer IUI any longer and suggests 2 years of sexual intercourse followed by IVF. This recommendation has generated an ongoing debate, with only 4% of all gynecologists in the UK discontinuing the use of IUI. We feel that it is high time to provide proper scientific evidence for the effectiveness of IUI, or lack thereof, and invite the medical community to start RCTs comparing IUI to sexual intercourse.

Long term outcome in subfertile couples with isolated cervical factor

OBJECTIVE

A previous randomized clinical trial (RCT) compared immediate treatment with intrauterine insemination (IUI) to expectant management for six months in subfertile couples with an isolated cervical factor. That study showed higher ongoing pregnancy rates in couples receiving intrauterine insemination. The current study compared the long-term effectiveness and costs of this intervention.

STUDY DESIGN

We followed all couples (N=99) who were previously included in the RCT for three years after randomization and registered pregnancies and treatments. After the initial trial period, couples in both groups were offered further treatment according to local protocol. The primary outcome was an ongoing pregnancy after three years.

RESULTS

After three years, there were 36 ongoing pregnancies in the immediate IUI group (N=51 couples) and 38 ongoing pregnancies in the expectant management group (N=48 couples). The ongoing pregnancy rates were 71% and 79% respectively (RR 0.89 (95% confidence interval (CI) 0.7-1.1)).

CONCLUSIONS

In couples with an isolated cervical factor, a treatment strategy including immediate treatment with IUI does not result in higher ongoing pregnancy rates on the long term. Initial expectant management is therefore justified in these couples and identifying a cervical factor by a post-coital test is unnecessary.

Pax gene diversity in the basal cnidarian Acropora millepora (Cnidaria, Anthozoa): implications for the evolution of the Pax gene family

Pax genes encode a family of transcription factors, many of which play key roles in animal embryonic development but whose evolutionary relationships and ancestral functions are unclear. To address these issues, we are characterizing the Pax gene complement of the coral Acropora millepora, an anthozoan cnidarian. As the simplest animals at the tissue level of organization, cnidarians occupy a key position in animal evolution, and the Anthozoa are the basal class within this diverse phylum. We have identified four Pax genes in Acropora: two (Pax-Aam and Pax-Bam) are orthologs of genes identified in other cnidarians; the others (Pax-Cam and Pax-Dam) are unique to Acropora. Pax-Aam may be orthologous with Drosophila Pox neuro, and Pax-Bam clearly belongs to the Pax-2/5/8 class. The Pax-Bam Paired domain binds specifically and preferentially to Pax-2/5/8 binding sites. The recently identified Acropora gene Pax-Dam belongs to the Pax-3/7 class. Clearly, substantial diversification of the Pax family occurred before the Cnidaria/higher Metazoa split. The fourth Acropora Pax gene, Pax-Cam, may correspond to the ancestral vertebrate Pax gene and most closely resembles Pax-6. The expression pattern of Pax-Cam, in putative neurons, is consistent with an ancestral role of the Pax family in neural differentiation and patterning. We have determined the genomic structure of each Acropora Pax gene and show that some splice sites are shared both between the coral genes and between these and Pax genes in triploblastic metazoans. Together, these data support the monophyly of the Pax family and indicate ancient origins of several introns.

Learning about the dynamic swallowing process using an interactive multimedia program

The management of dysphagia is the largest recognized subspecialty in the field of speech-language pathology. Practicing speech-language pathologists require a comprehensive theoretical and functional knowledge base to underpin the safe and effective management of people with dysphagia. Students need to develop an understanding of the normal integrated swallow and how it can be affected to appreciate the assessment or treatment of dysphagia. Although students are well motivated to learn this material, assimilating knowledge of the dynamic nature of the swallow has typically been problematic because of its complex character. The limitations of currently available teaching resources have been addressed by the production of an interactive multimedia program that includes integrated presentation of text, graphics, voice-overs, and video and animation sequences to highlight various aspects of the swallowing process. Students can selectively manipulate parts of this process to understand the normal swallow and to simulate different aspects of dysfunction and the consequent effects on swallow safety and efficiency. Feedback from students, faculty, and experts has demonstrated that The Dynamic Swallow would be a valued tool in the teaching of dysphagia.