Effectiveness of a Stigma Awareness Intervention on Reemployment of People with Mental Health Issues/Mental Illness: A Cluster Randomised Controlled Trial

PURPOSE

A barrier for reemployment of people with mental health issues/mental illness (MHI) is workplace stigma and discrimination. In this RCT the effectiveness of a stigma-awareness intervention addressing finding work, retaining work and decisional stress were evaluated.

METHODS

A cluster RCT was conducted in 8 Dutch municipal practices. Randomisation took place at practice level. Participants were unemployed people with MHI, receiving social benefits. The intervention consisted of a decision aid for workplace disclosure for participants and a 2 × 3 h stigma-awareness training for their employment specialists. Primary outcomes were measured at baseline, 3-, 6- and 12-months. Multilevel analyses, containing random intercepts of participants nested in organizations, were conducted to analyse the effects of the intervention.

RESULTS

Participants (N = 153) were randomized to an experimental (n = 76) or control group (n = 77). At six months, significantly more participants of the experimental group (51%) had found work compared to the control group (26%). At twelve months, significantly more participants of the experimental group (49%) had retained work compared to the control group (23%). Intention-to-treat analyses showed that randomization to the experimental group was associated with finding (OR(95%CI) = 7.78(1.33-45.53), p = 0.02) and retaining (OR(95%CI) = 12.15(2.81-52.63), p < 0.01) work more often at twelve months. Analyses showed that the experimental and control group did not differ in decisional stress.

CONCLUSIONS

Our stigma awareness intervention was effective for finding and retaining work. As the percentage of people who found and retained work almost doubled, this suggests that on a societal level, a vast number of unemployed people could be reemployed with a relatively simple intervention.

TRIAL REGISTRATION

The study was retrospectively registered at the Dutch Trial Register (TRN: NL7798, date: 04-06-2019).

Dutch workers' attitudes towards having a coworker with mental health issues or illness: a latent class analysis

Introduction

Workplace mental health stigma is a major problem as it can lead to adverse occupational outcomes and reduced well-being. Although workplace climate is largely determined by managers and co-workers, the role of co-workers in workplace stigma is understudied. Therefore, the aims are: (1) to examine knowledge and attitudes towards having a coworker with Mental Health Issues or Illness (MHI), especially concerning the desire for social distance, (2) to identify distinct subgroups of workers based on their potential concerns towards having a coworker with MHI, and (3) to characterize these subgroups in terms of knowledge, attitudes, and background characteristics.

Materials and methods

A cross-sectional survey was conducted among a nationally representative internet panel of 1,224 Dutch workers who had paid jobs and did not hold management positions. Descriptive statistics and a three-step approach Latent Class Analysis (LCA) were used to address the research aims.

Results

Concerning the desire for social distance, 41.9% of Dutch workers indicated they did not want to have a close colleague with MHI, and 64.1% did not want to work for a higher-ranking manager who had MHI. In contrast however, most workers did not have negative experiences with interacting with coworkers with MHI (92.6%). Next, five distinct subgroups (SG) of workers were identified: two subgroups with few concerns towards having a coworker with MHI (SG1 and SG2; 51.8% of the respondents), one subgroup with average concerns (SG3; 22.7% of the respondents), and two subgroups with more concerns (SG4 and SG5; 25.6% of the respondents). Four out of five subgroups showed a high tendency towards the desire for social distance. Nevertheless, even in the subgroups with more concerns, (almost) half of the respondents were willing to learn more about how to best deal with coworkers with MHI. No significant differences were found between the subgroups on background characteristics.

Discussion

The high tendency to the desire for social distance seems to contrast with the low number of respondents who personally had negative experiences with workers with MHI in the workplace. This suggests that the tendency to socially exclude this group was not based on their own experience. The finding that a large group of respondents indicated to want to learn more about how to deal with a co-worker with MHI is promising. Destigmatizing interventions in the workplace are needed in order to create more inclusive workplaces to improve sustained employment of people with MHI. These interventions should focus on increasing the knowledge of workers about how to best communicate and deal with coworkers with MHI, they do not need to differentiate in background variables of workers.

Perspectives on scientific error

Theoretical arguments and empirical investigations indicate that a high proportion of published findings do not replicate and are likely false. The current position paper provides a broad perspective on scientific error, which may lead to replication failures. This broad perspective focuses on reform history and on opportunities for future reform. We organize our perspective along four main themes: institutional reform, methodological reform, statistical reform and publishing reform. For each theme, we illustrate potential errors by narrating the story of a fictional researcher during the research cycle. We discuss future opportunities for reform. The resulting agenda provides a resource to usher in an era that is marked by a research culture that is less error-prone and a scientific publication landscape with fewer spurious findings.

FDA-approved drug screening in patient-derived organoids demonstrates potential of drug repurposing for rare cystic fibrosis genotypes

BACKGROUND

Preclinical cell-based assays that recapitulate human disease play an important role in drug repurposing. We previously developed a functional forskolin induced swelling (FIS) assay using patient-derived intestinal organoids (PDIOs), allowing functional characterization of CFTR, the gene mutated in people with cystic fibrosis (pwCF). CFTR function-increasing pharmacotherapies have revolutionized treatment for approximately 85% of people with CF who carry the most prevalent F508del-CFTR mutation, but a large unmet need remains to identify new treatments for all pwCF.

METHODS

We used 76 PDIOs not homozygous for F508del-CFTR to test the efficacy of 1400 FDA-approved drugs on improving CFTR function, as measured in FIS assays. The most promising hits were verified in a secondary FIS screen. Based on the results of this secondary screen, we further investigated CFTR elevating function of PDE4 inhibitors and currently existing CFTR modulators.

RESULTS

In the primary screen, 30 hits were characterized that elevated CFTR function. In the secondary validation screen, 19 hits were confirmed and categorized in three main drug families: CFTR modulators, PDE4 inhibitors and tyrosine kinase inhibitors. We show that PDE4 inhibitors are potent CFTR function inducers in PDIOs where residual CFTR function is either present, or created by additional compound exposure. Additionally, upon CFTR modulator treatment we show rescue of CF genotypes that are currently not eligible for this therapy.

CONCLUSION

This study exemplifies the feasibility of high-throughput compound screening using PDIOs. We show the potential of repurposing drugs for pwCF carrying non-F508del genotypes that are currently not eligible for therapies.

ONE-SENTENCE SUMMARY

We screened 1400 FDA-approved drugs in CF patient-derived intestinal organoids using the previously established functional FIS assay, and show the potential of repurposing PDE4 inhibitors and CFTR modulators for rare CF genotypes.

Maximizing agricultural reuse of recycled nutrients: A spatially explicit assessment of environmental consequences and costs

Recovering nutrients from organic materials to reduce artificial fertilizer inputs requires the implementation of processing technologies and can involve considerable logistics and transportation costs. Reducing such costs by directly applying organic materials to agricultural land can contribute to pollution due to potential contaminants and unbalanced nutrient ratios. Assessing the cost of increased recycling requires a spatially explicit approach because availability of organic materials, nutrient demand and agro-ecosystem properties vary spatially. A multi-objective model was developed to estimate the trade-offs between costs of nutrient recovery and improvements in nutrient distribution for a case study area in The Netherlands. The evaluated recovery processes included solid-liquid separation followed by reverse osmosis to recover nutrients from pig manure which was compared to a conventional process via hygienisation and export. Results indicate that, even in a nutrient saturated area, replacement potential of artificial nitrogen (N) and phosphorus (P) fertilizers through locally reclaimed nutrients is limited to about 17% N and 55% P. A cost optimum was found when about 48% of the initial pig manure quantities were processed via nutrient recovery and directed to land. Increasing manure processing for nutrient recovery led to a redistribution of nutrients and trace metals (zinc (Zn) and copper (Cu)), resulting in more localized concentration. Zn and Cu were enriched by about 8% and 2%, respectively, when maximizing nutrient recovery. Our generic model offers a methodology to assess the trade-offs between increased recycling and associated spatial effects to facilitate sustainable recycling infrastructures for achieving more circular agriculture.

The quality and the accuracy of codes for terminations of pregnancy for fetal anomalies recorded in hospital databases in three countries in northern Europe

BACKGROUND

The number of terminations of pregnancy for fetal anomalies in Europe (TOPFA) has increased over recent decades. Therefore, it is important that TOPFAs, in addition to all other birth outcomes, are included in the surveillance of congenital anomalies and in studies on possible teratogenic risks of pregnancy exposures. The aim of this study was to evaluate the quality and the accuracy of codes identifying TOPFA cases in hospital databases.

METHODS

TOPFA cases recorded in three EUROCAT congenital anomaly registries (Finland, 2010-2014; Funen in Denmark, 2005-2014; and northern Netherlands, 2013-2014) were linked to hospital databases using maternal IDs.

RESULTS

A total of 2,114 TOPFA cases over the study period were identified in the registries and 2,096 (99%) of these pregnancies were identified in the hospital databases. An end of pregnancy code was present for 91% of the cases and a code for a congenital anomaly was present for 82% (with some differences across registries). The proportion of TOPFA cases with a code for a specific congenital anomaly was <50% for cases with a structural anomaly (range 0%-50%) and 70% for cases with a chromosomal anomaly.

CONCLUSION

Hospital databases have limited information or codes to identify TOPFAs for specific anomalies and the data are not detailed enough for surveillance of congenital anomalies or for studies analyzing pregnancy exposures and risk of congenital anomalies. However, hospital data may be used to identify the occurrence of a TOPFA to enable more detailed information to be obtained from the medical records.

Expectations of Mental Illness Disclosure Outcomes in the Work Context: A Cross-Sectional Study Among Dutch Workers

Purpose The decision whether to disclose mental illness at work can have important positive and negative consequences for sustainable employment and well-being. The aim of the study is (1) to examine workers' expectations of outcomes of mental illness disclosure in the workplace and to evaluate their expectations regarding which factors are of influence on these outcomes, (2) to identify distinct subgroups of workers, and (3) to characterize these subgroups in terms of personal, sociodemographic, and work-related characteristics. Methods In this cross-sectional survey study, a sample of 1224 Dutch workers was used. Latent Class Analysis (LCA) was used to identify classes of workers based on expected workplace mental illness outcomes. A three-step approach LCA was chosen to investigate whether the classes differed in characteristics. Results The majority of workers expected predominantly positive outcomes of workplace mental illness disclosure (e.g., being able to be one's authentic self; 82.4%), even though they simultaneously expected disclosure to lead to advancement-related discrimination (e.g., lower chances of contract renewal; or getting a promotion; 68.4% and 57%, respectively). Six distinct subgroups of workers were identified based on expected workplace mental illness disclosure outcomes: two positive classes (50.1%), two negative classes (33.3%), and two classes who indicated not to know what the outcomes would be (16.7%). Significant differences between the classes were found on personal experience, work-related association with mental illness, gender, educational level, and workplace atmosphere. Conclusion The disclosure process is complex, as most workers were optimistic (i.e., expected generally positive outcomes) whilst simultaneously expecting workplace discrimination. Subgroup differences in expectations regarding workplace mental illness disclosure outcomes were found.

Epidemiology and management of nontuberculous mycobacterial disease in people with cystic fibrosis, the Netherlands

BACKGROUND

Nontuberculous mycobacteria (NTM) are opportunistic, difficult to treat pathogens. With increasing prevalence of NTM infections in people with cystic fibrosis (pwCF) and the improved life expectancy, the burden is expected to grow.

METHODS

We assessed the epidemiology and management of NTM isolation and disease in pwCF in the Netherlands using a survey and retrospective, case-controlled data from the Dutch CF Registry. We determined the isolation prevalence, treatment and outcomes from 2013-2019.

RESULTS

NTM isolation prevalence increased from 1.0% to 3.6% (2013-2019). This was a single NTM isolation in 53.7% of the adults and 60.0% of the children. M. abscessus and M. avium complex (MAC) were most frequent (47.1 and 30.9%). Of the treated pwCF, 48.5% attained culture conversion of M. abscessus; 54.5% for MAC. Children with an NTM isolation showed more infections with S. maltophilia and/or A. fumigatus (p < 0.001) compared to controls. In the year prior to NTM isolation, children in the NTM group had a lower mean FEV1% predicted (81.5 ± 16.7 vs. 88.6 ± 15.3, p = 0.024), while adults in the NTM group had more IV antibiotic days compared to controls (60 vs. 17, p = 0.047). In the following years, FEV1% predicted declined faster in pwCF with NTM than the control group (children: -3.8% vs. -1.6%, p = 0.023; adults: -0.7% and 0.4%, ns).

CONCLUSIONS

The isolation prevalence of 3.6%, poor treatment outcomes and associated lung function decline emphasize that NTM pulmonary disease (NTM-PD) is a significant health issue among pwCF in the Netherlands. Its prevention and treatment require increased attention.

Psychometric properties of the Internalized Stigma of Mental Illness (ISMI-10) scale in a Dutch sample of employees with mental illness

BACKGROUND

Internalized stigma can have numerous negative effects on the well-being and employment of people with mental illness. Brief, valid, and reliable measures are needed to get a better understanding of self-stigmatization. The aim of this study is to translate the brief version of the Internalized Stigma of Mental Illness (ISMI-10) scale into a Dutch version and to assess the reliability and validity of this Dutch version in a sample of employees with mental illness.

METHODS

The ISMI-10 was translated into Dutch using the forward-backward translation procedure. The sample consisted of 161 employees with mental illness. Internal consistency was evaluated and the retest reliability was tested with 68 respondents. The construct validity was evaluated by testing convergent and divergent validity.

RESULTS

The Dutch ISMI-10 showed good internal consistency (α = 0.83) and good test-retest reliability (r = 0.73). The Dutch ISMI-10 demonstrated excellent convergent validity; high correlations were found between the Dutch ISMI-10 and hope (r = -0.54), anxiety and depression (r = 0.59), self-esteem (r = -0.56), and empowerment (r = - 0.59). Acceptable divergent validity was indicated; small correlations were found between the Dutch ISMI-10 and the physical functioning subscale (r = -0.27) and the role limitation due to physical problems subscale (r = -0.21), and medium correlations were found between the Dutch ISMI-10 and the general health subscale (r = -0.36).

CONCLUSION

The Dutch ISMI-10 demonstrated adequate psychometric properties for assessing internalized stigma and can be used by researchers in Dutch speaking countries to get a better understanding of self-stigmatization among people with mental illness.

In What Ways Does Health Related Stigma Affect Sustainable Employment and Well-Being at Work? A Systematic Review

PURPOSE

Studies are increasingly showing that health related stigma is a barrier to employment, but it is not known how. The aim of this systematic review is to identify, appraise and analyse studies that have directly or indirectly addressed ways in which stigma affects sustainable employment and well-being at work of people with disabilities.

METHODS

Using a multiphase screening process, this review is based on a comprehensive literature search (2000-2019) carried out in six electronic databases: Embase, Web of Science, Medline Ovid, Cochrane CENTRAL, PsycINFO and Google Scholar.

RESULTS

7.263 publications were identified; 96 studies were found eligible to be included in the review. 72% of the studies were conducted in North America or Europe. Few studies directly assessed how stigma affects the employment of people with disabilities. Most studies highlighted that attitudes and behaviour of employers formed a barrier to employment, as well as anticipated stigma and self-stigma in people with health problems. However, the findings also showed that the attitudes and behaviour of co-workers, health care professionals, reintegration professionals, customers, and family and friends could act as a barrier to employment although these influences are under-researched. Although many similarities were seen in the relevant findings of studies about both physical and mental disabilities, several nuances were found.

CONCLUSION

Stigma hampers sustainable employment and well-being in multiple ways. Whereas the number of publications on this topic is rapidly increasing, the roles of health care professionals, reintegration professionals, co-workers, customers, and family and friends particularly warrant more attention.

Analysis of early neonatal case fatality rate among newborns with congenital hydrocephalus, a 2000-2014 multi-country registry-based study

BACKGROUND

Congenital hydrocephalus (CH) comprises a heterogeneous group of birth anomalies with a wide-ranging prevalence across geographic regions and registry type. The aim of the present study was to analyze the early neonatal case fatality rate (CFR) and total birth prevalence of newborns diagnosed with CH.

METHODS

Data were provided by 25 registries from four continents participating in the International Clearinghouse for Birth Defects Surveillance and Research (ICBDSR) on births ascertained between 2000 and 2014. Two CH rates were calculated using a Poisson distribution: early neonatal CFR (death within 7 days) per 100 liveborn CH cases (CFR) and total birth prevalence rate (BPR) per 10,000 births (including live births and stillbirths) (BPR). Heterogeneity between registries was calculated using a meta-analysis approach with random effects. Temporal trends in CFR and BPR within registries were evaluated through Poisson regression modeling.

RESULTS

A total of 13,112 CH cases among 19,293,280 total births were analyzed. The early neonatal CFR was 5.9 per 100 liveborn cases, 95% confidence interval (CI): 5.4-6.8. The CFR among syndromic cases was 2.7 times (95% CI: 2.2-3.3) higher than among non-syndromic cases (10.4% [95% CI: 9.3-11.7] and 4.4% [95% CI: 3.7-5.2], respectively). The total BPR was 6.8 per 10,000 births (95% CI: 6.7-6.9). Stratified by elective termination of pregnancy for fetal anomalies (ETOPFA), region and system, higher CFR were observed alongside higher BPR rates. The early neonatal CFR and total BPR did not show temporal variation, with the exception of a CFR decrease in one registry.

CONCLUSIONS

Findings of early neonatal CFR and total BPR were highly heterogeneous among registries participating in ICBDSR. Most registries with higher CFR also had higher BPR. Differences were attributable to type of registry (hospital-based vs. population-based), ETOPFA (allowed yes or no) and geographical regions. These findings contribute to the understanding of regional differences of CH occurrence and early neonatal deaths.

A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log₁₀ increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence.

Adapting active case-finding for TB during the COVID-19 pandemic in Yogyakarta, Indonesia

The COVID-19 pandemic and response measures, including lockdowns and the reorientation of health services, have disrupted essential health services for other diseases, including TB, HIV and malaria. For TB, reductions in case detection due to the COVID-19 pandemic are projected to result in increased TB transmission, morbidity and mortality. Active case-finding (ACF) for TB using community-based approaches is a potential strategy to offset reductions in TB detection by obviating the need for patients to seek care at a health facility. A number of approaches can be used to conduct TB ACF safely and screen designated target populations while managing the risks of SARS-CoV-2 transmission for staff, individuals and the community. We present a framework of options for and experience of adapting TB ACF services in response to the challenges of COVID-19 in our programme in Yogyakarta, Indonesia. Key changes have included revised prioritisation of target populations focusing on household contacts, reducing case-finding throughput, implementation of additional infection control measures and precautions, and integration of COVID-19 screening among those being screened for TB. Our approach could inform other programmes seeking to adapt TB ACF services to mitigate the negative impact of COVID-19 on TB case detection.

OP0257-PARE USING PATIENT HEALTH LITERACY PROFILES TO IDENTIFY SOLUTIONS TO CHALLENGES FACED IN RHEUMATOLOGY CARE

Background:

The prevalence of limited health literacy (i.e. cognitive and social resources of individuals to access, understand and apply health information to promote and maintain good health) in the Netherlands is estimated to be over 36% [1]. Access to and outcomes of rheumatological care may be compromised by limited patient health literacy, yet little is known about how to address this, thus action is required. As influencing individual patients’ health literacy in the rheumatology context is often unrealistic, it is paramount for the health system to be tailored to the health literacy needs of its patients. The OPtimising HEalth LIteracy and Access (Ophelia) process offers a method to inform system change [2].

Objectives:

Following the Ophelia approach:

Methods:

Patients with RA, SpA and gout attending outpatient clinics in three centres in the Netherlands completed the Health Literacy Questionnaire (HLQ) and questions on socio-demographic and health-related characteristics. Hierarchical cluster analysis using Ward’s method identified clusters based on the nine HLQ domains. Three researchers jointly examined 24 cluster solutions for meaningfulness by interpreting HLQ domain scores and patient characteristics. Meaningful clusters were translated into health literacy profiles using HLQ patterns and demographic data. A patient research partner confirmed the identified profiles. Patient vignettes were designed by combining cluster analyses results with qualitative patient interviews. The vignettes were used in two two-hour co-design workshops with rheumatologists and nurses to discuss their perspective on health literacy-related challenges for patients and professionals, and generate ideas on how to address these challenges.

Results:

In total, 895 patients participated: 49% female, mean age 61 years (±13.0), 25% lived alone, 18% had a migrant background, 6.6% did not speak Dutch at home and 51% had low levels of education. Figure 1 shows a heat map of identified health literacy profiles, displaying the score distribution per profile across nine health literacy domains. Figure 2 shows an excerpt of a patient vignette, describing challenges for a patient with profile number 9. The workshops were attended by 7 and 14 nurses and rheumatologists. Proposed solutions included health literacy communication training for professionals, developing and improving (visual) patient information materials, peer support for patients through patient associations or group consultations, a clear referral system for patients who need additional guidance by a nurse, social worker, lifestyle coach, pharmacist or family doctor, and more time with rheumatology nurses for target populations. Moreover, several system adaptations to the clinic, such as a central desk for all patient appointments, were proposed.

Conclusion:

This study identified several distinct health literacy profiles of patients with rheumatic conditions. Engaging with health professionals in co-design workshops led to numerous bottom-up ideas to improve care. Next steps include co-design workshops with patients, followed by prioritising and testing proposed interventions.

References:

[1]Heijmans M. et al. Health Literacy in the Netherlands. Utrecht: Nivel 2018

[2]Batterham R. et al. BMC Public Health 2014, 14:694

Disclosure of Interests:

Mark Bakker: None declared, Polina Putrik: None declared, Jany Rademakers Speakers bureau: In March 2017, Prof. Dr. Rademakers was invited to speak about health literacy at the “Heuvellanddagen” Conference, hosted by Janssen-Cilag., Mart van de Laar Consultant of: Sanofi Genzyme, Speakers bureau: Sanofi Genzyme, Harald Vonkeman: None declared, Marc R Kok Grant/research support from: BMS and Novartis, Consultant of: Novartis and Galapagos, Hanneke Voorneveld: None declared, Sofia Ramiro Grant/research support from: MSD, Consultant of: Abbvie, Lilly, Novartis, Sanofi Genzyme, Speakers bureau: Lilly, MSD, Novartis, Maarten de Wit Grant/research support from: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Consultant of: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Speakers bureau: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Richard Osborne Consultant of: Prof. Osborne is a paid consultant for pharma in the field of influenza and related infectious diseases., Roy Batterham: None declared, Rachelle Buchbinder: None declared, Annelies Boonen Grant/research support from: AbbVie, Consultant of: Galapagos, Lilly (all paid to the department)

The experiences of Dutch fathers on fathering children with disabilities: 'Hey, that is a father and his daughter, that is it'

BACKGROUND

Due to a predominant focus on mothers, fathers of children with disabilities are greatly overlooked in research. One could argue that there is a lack of research on the multifaceted nature of fatherhood altogether. Therefore, this study aims to gain insight into the perceived experiences of fathers of children with disabilities.

METHODS

These perceptions were studied by analysing data generated through semi-structured interviews, which were conducted with 12 Dutch fathers of children or young adults with disabilities.

RESULTS

Categories found during our data analysis were similar to those illustrated in the 'conceptual framework on responsible fathering' by including role identification, commitment, employment characteristics, cultural expectations and social support.

CONCLUSIONS

Overall, the fathers in this study reported similar experiences, but this study identified new life perspective as an additional category, which might be specific for fathers of children with disabilities. This new life perspective included a positive attitude, living in the moment, appreciation of the little things and transformation of expectations. Some fathers expressed that their child(ren) has enriched their lives, which positively influenced their fathering experience.

High Treatment Uptake in Human Immunodeficiency Virus/Hepatitis C Virus-Coinfected Patients After Unrestricted Access to Direct-Acting Antivirals in the Netherlands

Background

The Netherlands has provided unrestricted access to direct-acting antivirals (DAAs) since November 2015. We analyzed the nationwide hepatitis C virus (HCV) treatment uptake among patients coinfected with human immunodeficiency virus (HIV) and HCV.

Methods

Data were obtained from the ATHENA HIV observational cohort in which >98% of HIV-infected patients ever registered since 1998 are included. Patients were included if they ever had 1 positive HCV RNA result, did not have spontaneous clearance, and were known to still be in care. Treatment uptake and outcome were assessed. When patients were treated more than once, data were included from only the most recent treatment episode. Data were updated until February 2017. In addition, each treatment center was queried in April 2017 for a data update on DAA treatment and achieved sustained virological response.

Results

Of 23574 HIV-infected patients ever linked to care, 1471 HCV-coinfected patients (69% men who have sex with men, 15% persons who [formerly] injected drugs, and 15% with another HIV transmission route) fulfilled the inclusion criteria. Of these, 87% (1284 of 1471) had ever initiated HCV treatment between 2000 and 2017, 76% (1124 of 1471) had their HCV infection cured; DAA treatment results were pending in 6% (92 of 1471). Among men who have sex with men, 83% (844 of 1022) had their HCV infection cured, and DAA treatment results were pending in 6% (66 of 1022). Overall, 187 patients had never initiated treatment, DAAs had failed in 14, and a pegylated interferon-alfa-based regimen had failed in 54.

Conclusions

Fifteen months after unrestricted DAA availability the majority of HIV/HCV-coinfected patients in the Netherlands have their HCV infection cured (76%) or are awaiting DAA treatment results (6%). This rapid treatment scale-up may contribute to future HCV elimination among these patients.

Predicting factors for chronic colonization of Pseudomonas aeruginosa in bronchiectasis

About 25% of the patients with bronchiectasis are likely to develop a chronic colonization with Pseudomonas aeruginosa. A better understanding of predictors of acquiring Pseudomonas within the patient population may facilitate future focused research. The aim of this retrospective observational study was to investigate predicting factors for P. aeruginosa colonization in patients with bronchiectasis. This was a single-center retrospective cohort study using a bronchiectasis database which consisted of 211 patients with bronchiectasis. Data were collected for demographic details, etiology, spirometry, microbiology data, maintenance medication use, exacerbation frequency, hospital admission rate, and FACED and Bronchiectasis Severity Index (BSI) score. Two hundred eleven patients were identified from our bronchiectasis database. Overall, 25% of the patients (n = 53) had a chronic colonization with P. aeruginosa. Seventeen patients (8%) died in a 5-year follow-up period of whom 7 (41%) had a chronic P. aeruginosa colonization (p > 0.05). After multiple regression analysis, P. aeruginosa-positive patients were significantly associated with an older age (> 55 years) (p = 0.004), the use of hypertonic saline (0.042), and inhalation antibiotics (< 0.001). Furthermore, the presence of PCD (p < 0.001) and post-infectious etiology (p < 0.001) as underlying causes were significantly associated with P. aeruginosa colonization. We observed that independent predictors for P. aeruginosa colonization were age > 55 years, hypertonic saline, and PCD, and post-infectious etiology as underlying causes of bronchiectasis. Since prevention of P. aeruginosa colonization is an important aim in the treatment of bronchiectasis, more attention could be directed to these groups at risk for Pseudomonas colonization.

Making stratigraphy in the Anthropocene: climate change impacts and economic conditions controlling the supply of sediment to Lake Geneva

The Anthropocene has been proposed as a profound, globally synchronous rupture in the history of the Earth System with its current state fundamentally different to that of the Holocene and driven by the geological force of human activity. Here, we show how stratigraphy is being made in a lake that is heavily impacted upon by climate change and human activities. For one of the largest inner-Alpine catchments in the European Alps, we draw attention to how sedimentation rates are a product of non-stationary, reflexive, human actions. In Lake Geneva, we identify both a human-induced climate change (HCC) signature and the effects of a recent economic shock on sediment extraction upon sediment loading to and sedimentation rates in the lake. The HCC signature thus reflects the nature of climate change impacts in this basin, where sediment accumulation rates evolve with climate, but where economic conditions contribute to shifts in the supply of sediment to the lake. Following social theory, we call this glocalization because of the combined importance and inseparability of human impacts across different spatial scales. The nature of human impacts on sediment delivery to the lake mean that the influence of humans is unlikely to be captured in the long-term depositional record.

Metformin exposure in first trimester of pregnancy and risk of all or specific congenital anomalies: exploratory case-control study

OBJECTIVE

To investigate whether exposure to metformin during the first trimester of pregnancy, for diabetes or other indications, increases the risk of all or specific congenital anomalies.

DESIGN

Population based exploratory case-control study using malformed controls. Cases of 29 specific subgroups of non-genetic anomalies, and all non-genetic anomalies combined, were compared with controls (all other non-genetic anomalies or genetic syndromes).

SETTING

11 EUROmediCAT European congenital anomaly registries surveying 1 892 482 births in Europe between 2006 and 2013.

PARTICIPANTS

50 167 babies affected by congenital anomaly (41 242 non-genetic and 8925 genetic) including live births, fetal deaths from 20 weeks' gestation, and terminations of pregnancy for fetal anomaly.

MAIN OUTCOME MEASURE

Odds ratios adjusted for maternal age, registry, multiple birth, and maternal diabetes status.

RESULTS

168 babies affected by congenital anomaly (141 non-genetic and 27 genetic) were exposed to metformin, 3.3 per 1000 births. No evidence was found for a higher proportion of exposure to metformin during the first trimester among babies with all non-genetic anomalies combined compared with genetic controls (adjusted odds ratio 0.84, 95% confidence interval 0.55 to 1.30). The only significant result was for pulmonary valve atresia (adjusted odds ratio 3.54, 1.05 to 12.00, compared with non-genetic controls; 2.86, 0.79 to 10.30, compared with genetic controls).

CONCLUSIONS

No evidence was found for an increased risk of all non-genetic congenital anomalies combined following exposure to metformin during the first trimester, and the one significant association was no more than would be expected by chance. Further surveillance is needed to increase sample size and follow up the cardiac signal, but these findings are reassuring given the increasing use of metformin in pregnancy.

Effectiveness of 12-13-week scan for early diagnosis of fetal congenital anomalies in the cell-free DNA era

OBJECTIVES

The main aim of this study was to assess the proportion and type of congenital anomalies, both structural and chromosomal, that can be detected at an early scan performed at 12-13 weeks' gestation, compared with at the 20-week structural anomaly scan offered under the present screening policy. Secondary aims were to evaluate the incidence of false-positive findings and ultrasound markers at both scans, and parental choice regarding termination of pregnancy (TOP).

METHODS

Sonographers accredited for nuchal translucency (NT) measurement were asked to participate in the study after undergoing additional training to improve their skills in late first-trimester fetal anatomy examination. The early scans were performed according to a structured protocol, in six ultrasound practices and two referral centers in the north-east of The Netherlands. All women opting for the combined test (CT) or with an increased a-priori risk of fetal anomalies were offered a scan at 12-13 weeks' gestation (study group). All women with a continuing pregnancy were offered, as part of the 'usual care', a 20-week anomaly scan.

RESULTS

The study group consisted of 5237 women opting for the CT and 297 women with an increased a-priori risk of anomalies (total, 5534). In total, 51 structural and 34 chromosomal anomalies were detected prenatally in the study population, and 18 additional structural anomalies were detected after birth. Overall, 54/85 (63.5%) anomalies were detected at the early scan (23/51 (45.1%) structural and all chromosomal anomalies presenting with either an increased risk at first-trimester screening or structural anomalies (31/34)). All particularly severe anomalies were detected at the early scan (all cases of neural tube defect, omphalocele, megacystis, and multiple severe congenital and severe skeletal anomalies). NT was increased in 12/23 (52.2%) cases of structural anomaly detected at the early scan. Of the 12 cases of heart defects, four (33.3%) were detected at the early scan, five (41.7%) at the 20-week scan and three (25.0%) after birth. False-positive diagnoses at the early scan and at the 20-week scan occurred in 0.1% and 0.6% of cases, respectively, whereas ultrasound markers were detected in 1.4% and 3.0% of cases, respectively. After first- or second-trimester diagnosis of an anomaly, parents elected TOP in 83.3% and 25.8% of cases, respectively.

CONCLUSIONS

An early scan performed at 12-13 weeks' gestation by a competent sonographer can detect about half of the prenatally detectable structural anomalies and 100% of those expected to be detected at this stage. Particularly severe anomalies, often causing parents to choose TOP, are amenable to early diagnosis. The early scan is an essential part of modern pregnancy care. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Tuberculosis and other causes of uveitis in Indonesia

PurposeThe purpose of this study is to assess the causes of uveitis in Indonesia and determine the importance of tuberculosis (TB) as a cause of uveitis.Patients and methodsProspective cohort study examining 146 consecutive new human immunodeficiency virus-negative patients with active uveitis between June 2014 and May 2015. We assessed the anatomic locations and specific causes of uveitis, as well as associations with infectious and non-infectious systemic diseases. We determined the prevalence of positive QuantiFERON Tb Gold test (QFT) results in Indonesian patients with uveitis and calculated the number of patients with active systemic TB.ResultsPosterior and panuveitis were the most common anatomic entities (38% each). Infections represented the most frequent cause of uveitis (33%); the most prevalent were toxoplasmosis (19%) and active systemic TB (8%). The majority of patients were QFT positive (61%). A specific diagnosis could not be established in 45% of the patients. At first presentation to the ophthalmologist, the majority of patients (66%) had a visual acuity of less than finger counting at 3 m and already exhibited various complications of uveitis. When classifying the QFT-positive patients with unexplained uveitis into a TB-related group, the percentage of 'TB-associated' uveitis cases increased from 8-48%. Highly elevated QFT levels were observed in patients with uveitis of unknown cause and no signs of active systemic TB.ConclusionsIn Indonesia, infectious uveitis was the most common type of uveitis and the leading causes consisted of toxoplasmosis and TB. The association observed between highly elevated QFT results and uveitis of otherwise unexplained origins indicates that a link exists between the latent TB infection and the development of uveitis.

Gastroschisis in Europe - A Case-malformed-Control Study of Medication and Maternal Illness during Pregnancy as Risk Factors

BACKGROUND

Gastroschisis, a congenital anomaly of the abdomen, is associated with young maternal age and has increased in prevalence in many countries. Maternal illness and medication exposure are among environmental risk factors implicated in its aetiology.

METHODS

A population-based case-malformed control study was conducted using data from 18 European congenital anomaly registries, with information on first trimester medication use, covering 8 million births 1995-2012. 1577 gastroschisis cases (of which 4% stillbirths, 11% terminations of pregnancy) were compared to 153 357 non-chromosomal/monogenic controls. Literature review identified previous associations concerning maternal illness and medication exposure to be tested as signals. Logistic regression adjusted for maternal age group, registry, and time period was used to evaluate associations.

RESULTS

Comparing gastroschisis to other congenital anomalies, the data supported signals concerning maternal depression (aOR 2.52, 95% CI 1.45, 4.39), antidepressant use (aOR 2.03, 95% CI 1.22, 3.38), postnatal depression/psychosis following a previous pregnancy (aOR 8.32, 95% CI 2.56, 27.01), sexually transmitted infections (aOR 2.85, 95% CI 1.13, 7.24), topical antivirals (aOR 5.31, 95% CI 1.63, 17.33), and continuation of oral contraceptives in early pregnancy (aOR 2.17, 95% CI 1.13, 4.18). Exploratory analyses suggested associations with a wider range of maternal infections and medications, including tonsillitis and the expectorant bromhexine.

CONCLUSIONS

While it is difficult to disentangle the effects of the medication and underlying indication, our results add to the evidence base on preventable risk factors for gastroschisis. These risk factors may contribute to the higher risk among young mothers, and geographical and temporal variation in prevalence.

Total pregnancy loss after chorionic villus sampling and amniocentesis: a cohort study

OBJECTIVES

To identify maternal-, operator- and procedure-related variables that affect procedure-related pregnancy loss after transcervical (TC) and transabdominal (TA) chorionic villus sampling (CVS) and amniocentesis and to estimate the rates of spontaneous and procedure-related loss in comparable subgroups of women.

METHODS

This was a retrospective cohort study conducted at the University Medical Center Groningen and the Academic Medical Center, The Netherlands. Databases of both centers were searched to identify singleton pregnancies that had undergone a combined test and/or anomaly scan at around 20 weeks' gestation, or an invasive procedure (CVS and/or amniocentesis) between January 2001 and December 2011. Maternal characteristics, obstetric history, technical aspects of the invasive procedure, ultrasound examinations and fetal and neonatal outcomes were available for 29 201 cases. Women were categorized, according to the type of examination they had received, into the following five groups: first-trimester combined test (and 20-week anomaly scan); 20-week anomaly scan only; CVS; amniocentesis; amniocentesis after unsuccessful CVS. Rates of fetal loss were compared between groups.

RESULTS

Variables significantly associated with a higher rate of fetal loss were, for CVS, repeat attempts during the procedure, use of TC cannula instead of biopsy forceps, gestational age at procedure ≥ 13 weeks and a pregnancy after assisted reproductive techniques, and, for amniocentesis, if indication was fetal anomaly or family history of anomalies and repeat attempts during the procedure. In women aged ≥ 36 years who did not undergo an invasive procedure, spontaneous fetal loss rate (FLR) after first-trimester combined test was 1.40%, whereas after CVS, FLR was 2.76% and 2.43% for a TC and TA approach, respectively. The additional risk of fetal loss with TC-CVS was therefore 1.36% (1 : 74), which varied according to the instrument used (0.27% for forceps and 3.12% for cannula), and with TA-CVS was 1.03% (1 : 97). In women aged ≥ 36 years who underwent a 20-week anomaly scan only, spontaneous FLR was 0.63%. In women who underwent amniocentesis solely because of advanced maternal age, FLR was 1.11%. The additional risk of fetal loss with amniocentesis was 0.48% (1 : 208).

CONCLUSION

The total rate of procedure-related fetal loss after TA- and TC-CVS and amniocentesis appears lower than the risks on which women are currently counseled. There was a trend for a decrease in risk when the level of experience of the operator increased. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Scripting MODFLOW Model Development Using Python and FloPy

Graphical user interfaces (GUIs) are commonly used to construct and postprocess numerical groundwater flow and transport models. Scripting model development with the programming language Python is presented here as an alternative approach. One advantage of Python is that there are many packages available to facilitate the model development process, including packages for plotting, array manipulation, optimization, and data analysis. For MODFLOW-based models, the FloPy package was developed by the authors to construct model input files, run the model, and read and plot simulation results. Use of Python with the available scientific packages and FloPy facilitates data exploration, alternative model evaluations, and model analyses that can be difficult to perform with GUIs. Furthermore, Python scripts are a complete, transparent, and repeatable record of the modeling process. The approach is introduced with a simple FloPy example to create and postprocess a MODFLOW model. A more complicated capture-fraction analysis with a real-world model is presented to demonstrate the types of analyses that can be performed using Python and FloPy.

EUROmediCAT signal detection: a systematic method for identifying potential teratogenic medication

AIMS

Information about medication safety in pregnancy is inadequate. We aimed to develop a signal detection methodology to routinely identify unusual associations between medications and congenital anomalies using data collected by 15 European congenital anomaly registries.

METHODS

EUROmediCAT database data for 14 950 malformed foetuses/babies with first trimester medication exposures in 1995-2011 were analyzed. The odds of a specific medication exposure (coded according to chemical substance or subgroup) for a specific anomaly were compared with the odds of that exposure for all other anomalies for 40 385 medication anomaly combinations in the data. Simes multiple testing procedure with a 50% false discovery rate (FDR) identified associations least likely to be due to chance and those associations with more than two cases with the exposure and the anomaly were selected for further investigation. The methodology was evaluated by considering the detection of well-known teratogens.

RESULTS

The most common exposures were genitourinary system medications and sex hormones (35.2%), nervous system medications (28.0%) and anti-infectives for systemic use (25.7%). Fifty-two specific medication anomaly associations were identified. After discarding 10 overlapping and three protective associations, 39 associations were selected for further investigation. These associations included 16 which concerned well established teratogens, valproic acid (2) and maternal diabetes represented by use of insulin (14).

CONCLUSIONS

Medication exposure data in the EUROmediCAT central database can be analyzed systematically to determine a manageable set of associations for validation and then testing in independent datasets. Detection of teratogens depends on frequency of exposure, level of risk and teratogenic specificity.

Strategies for disseminating recommendations or guidelines to patients: a systematic review

Background

The aim of this systematic literature review was to assess what dissemination strategies are feasible to inform and educate patients about recommendations (also known as guidelines).

Methods

The search was performed in February 2016 in PubMed, Ebsco/PsycINFO, Ebsco/CINAHL and Embase. Studies evaluating dissemination strategies, involving patients and/or reaching patients, were included. A hand search and a search in the grey literature, also done in February 2016, were added. Searches were not restricted by language or publication type.

Publications that referred to (1) guideline(s) or recommendation(s), (2) dissemination, (3) dissemination with patients/patient organisations and (4) dissemination to patients/patient organisations were included in this article. Criteria 1 AND 2 were mandatory together with criteria 3 OR 4.

Results

The initial search revealed 3753 unique publications. Forty-seven articles met the inclusion criteria and were selected for detailed review. The hand search and grey literature resulted in four relevant articles. After reading the full text of the 47 articles, 21 were relevant for answering our research question. Most publications had low levels of evidence, 3 or 4 of the Oxford levels of evidence. One article had a level of evidence of 2(b).

This article gives an overview of tools and strategies to disseminate recommendations to patients. Key factors of success were a dissemination plan, written at the start of the recommendation development process, involvement of patients in this development process and the use of a combination of traditional and innovative dissemination tools. The lack of strong evidence calls for more research of the effectiveness of different dissemination strategies as well as the barriers for implementing a strategic approach of dissemination.

Conclusion

Our findings provide the first systematic overview of tools and strategies to disseminate recommendations to patients and patient organisations. Participation of patients in the whole process is one of the most important findings. These findings are relevant to develop, implement and evaluate more (effective) dissemination strategies which can improve health care.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0447-x) contains supplementary material, which is available to authorized users.

Lamotrigine use in pregnancy and risk of orofacial cleft and other congenital anomalies

OBJECTIVE

To test previous signals of a risk of orofacial cleft (OC) and clubfoot with exposure to the antiepileptic lamotrigine, and to investigate risk of other congenital anomalies (CA).

METHODS

This was a population-based case-malformed control study based on 21 EUROCAT CA registries covering 10.1 million births (1995-2011), including births to 2005 in which the clubfoot signal was generated and a subsequent independent study population of 6.3 million births. A total of 226,806 babies with CA included livebirths, stillbirths, and terminations of pregnancy following prenatal diagnosis. First-trimester lamotrigine monotherapy exposure in OC cases and clubfoot cases was compared to other nonchromosomal CA (controls). Odds ratios (OR) were adjusted for registry. An exploratory analysis compared the proportion of each standard EUROCAT CA subgroup among all babies with nonchromosomal CA exposed to lamotrigine monotherapy with non-AED exposed pregnancies.

RESULTS

There were 147 lamotrigine monotherapy-exposed babies with nonchromosomal CA. For all OC, ORadj was 1.31 (95% confidence interval [CI] 0.73-2.33), isolated OC 1.45 (95% CI 0.80-2.63), isolated cleft palate 1.69 (95% CI 0.69-4.15). Overall ORadj for clubfoot was 1.83 (95% CI 1.01-3.31) and 1.43 (95% CI 0.66-3.08) in the independent study population. No other specific CA were significantly associated with lamotrigine monotherapy.

CONCLUSIONS

The risk of OC was not significantly raised and we estimate the excess risk of OC to be less than 1 in every 550 exposed babies. We have not found strong independent evidence of a risk of clubfoot subsequent to our original signal. Our study cannot assess the general malformation risk among lamotrigine-exposed pregnancies.

Reactive transport modeling of subsurface arsenic removal systems in rural Bangladesh

Subsurface Arsenic Removal (SAR) is a technique for in-situ removal of arsenic from groundwater. Extracted groundwater is aerated and re-injected into an anoxic aquifer, where the oxygen in the injected water reacts with ferrous iron in the aquifer to form hydrous ferric oxide (HFO). Subsequent extraction of groundwater contains temporarily lower As concentrations, because As sorbs onto the HFO. Injection, storage, and extraction together is called a cycle. A reactive transport model (RTM) was developed in PHREEQC to determine the hydrogeochemical processes responsible for As (im)mobilization during experimental SAR operation performed in Bangladesh. Oxidation of Fe(II) and As(III) were modeled using kinetic-rate expressions. Cation exchange, precipitation of HFO, and surface complexation, were modeled as equilibrium processes. A best set of surface complexation reactions and corresponding equilibrium constants was adopted from previous studies to simulate all 20 cycles of a SAR experiment. The model gives a reasonable match with observed concentrations of different elements in the extracted water (e.g., the r(2) value of As was 0.59 or higher). As concentrations in the extracted water are governed by four major processes. First, As concentration decreases in response to the elevated pH of injection water and likewise increases when native neutral pH groundwater flows in. Second, the sorption capacity for As increases due to the gradual buildup of HFO. Third, As sorption is enhanced by preferential removal of As(V). Fourth, competitive sorption of Si limits the capacity of freshly precipitated HFO for As sorption. Transferability of the developed reactive transport model was demonstrated through successful application of the model, without further calibration, to two additional SAR sites in Bangladesh. This gives confidence that the model could be useful to assess potential SAR performance at locations in Bangladesh based on local hydrogeochemical conditions.

Fetal facial profile markers of Down syndrome in the second and third trimesters of pregnancy

OBJECTIVES

To investigate the use of the maxilla-nasion-mandible (MNM) angle and fetal profile (FP) line to assess the degree of midfacial hypoplasia in Down-syndrome fetuses in the second and third trimesters of pregnancy.

METHODS

The MNM angle and FP line were measured retrospectively in stored two-dimensional images or three-dimensional volumes of fetuses with Down syndrome. Data collected from January 2006 to July 2013 were retrieved from the digital databases of participating units. The MNM angle was expressed as a continuous variable (degrees) and the FP line as positive, negative or zero. Measurements were obtained from stored images in the midsagittal plane by two experienced examiners and compared with our previously reported normal ranges for euploid fetuses. A MNM angle below the 5(th) centile of the reference range and a positive or negative FP line were considered as abnormal.

RESULTS

A total of 133 fetuses with Down syndrome were available for analysis, eight of which were subsequently excluded because of inadequate images. The MNM angle was not influenced by gestational age (P = 0.48) and was significantly smaller in Down-syndrome fetuses than in euploid fetuses (mean, 12.90° vs 13.53°, respectively; P = 0.015). The MNM angle was below the 5th centile for euploid fetuses in 16.8% of fetuses with Down syndrome (P < 0.01). In the cohort of Down-syndrome fetuses, a positive FP line was present in 41.6% of cases (with a false-positive rate (FPR) of 6.3%) and was positively correlated with Down syndrome and gestational age (P < 0.01). There was no case with a negative FP line. In cases of Down syndrome, a positive FP line was correlated with a small MNM angle (P < 0.01).

CONCLUSIONS

A small MNM angle and a positive FP line can be regarded as novel markers for Down syndrome. The FP line is an easy marker to measure, has a low FPR, does not require knowledge of normal reference values and has the potential to differentiate between Down syndrome and trisomy 18, as, in the latter, the FP line is often negative.

Facial profile markers in second- and third-trimester fetuses with trisomy 18

OBJECTIVES

To evaluate nasal bone length (NBL), maxilla-nasion-mandible (MNM) angle, fetal profile (FP) line, prenasal thickness (PT), prenasal thickness to nasal bone length (PT:NBL) ratio and prefrontal space ratio (PFSR) as markers of trisomy 18 in the second and third trimesters of pregnancy.

METHODS

The NBL, MNM angle, FP line, PT, PT:NBL ratio and PFSR were measured retrospectively from stored two-dimensional images or three-dimensional volumes of trisomy-18 fetuses, and were compared with our previously reported normal ranges for euploid fetuses. Additional ultrasound findings were noted at initial routine second-trimester scan and at subsequent advanced ultrasound examination performed after referral for karyotyping.

RESULTS

A total of 43 trisomy-18 fetuses were included in the analysis. At initial examination, median gestational age was 21 + 2 weeks. NBL and PT were correlated with gestational age (P < 0.001), but the other markers were not. Mean NBL, MNM angle, PT, PT:NBL ratio and PFSR were 3.76 mm, 16.67°, 4.25 mm, 1.39 and 0.87, respectively. The FP line was zero (normal) in 53.7% of cases and negative (abnormal) in 46.3%. All markers were significantly associated with trisomy 18, with the PT:NBL ratio yielding the highest detection rate (88.4%) followed by NBL (83.7%), MNM angle (56.4%), FP line (46.3%), PT (27.9%) and the PFSR (20.5%) (for a 5% false-positive rate for the continuous variables). Various combinations of the four best markers (NBL, FP line, MNM angle and PT:NBL ratio) yielded detection rates of between 72% and 95%. Structural anomalies were not detected in 22% of fetuses at the initial scan and in 2% at the advanced scan.

CONCLUSIONS

The PT:NBL ratio and NBL are robust second- and third-trimester markers for trisomy 18. A negative FP line has a 0% false-positive rate and the potential to differentiate between trisomy 18 and Down syndrome, as in the latter the FP line is often positive. No major anomaly was observed at the initial scan in about a quarter of trisomy-18 fetuses, underlining the role of second-trimester facial marker evaluation.

Factors controlling the oral bioaccessibility of anthropogenic Pb in polluted soils

In human risk assessment, ingestion of soil is considered a major route of toxic Pb exposure. A large body of research has focussed on the measurement of the 'total' Pb contents in sediment, soil and dust as a measure for the exposure to lead. We report that Pb bioaccessibility (i.e. the maximum bioavailability), determined with an in vitro test, does not necessarily depend on the total Pb content. In contrast, the Pb bioaccessibility is initially controlled by the chemical form and particle size of the Pb source, which in turn determine its solubility. Furthermore, when anthropogenic Pb resides within the soil, it may form new, more stable, minerals and/or binds to organic matter, clay, reactive iron or other reactive phases, changing its bioaccessibility. The bioaccessible Pb fraction of 28 soils, polluted with various Pb sources (including residues of Pb bullets and pellets, car battery Pb, city waste and diffuse Pb), was determined with an in vitro-test and varied from 0.5% to 79.0% of total Pb. The highest Pb bioaccessibility (60.7% to 79.0%) was measured in soils polluted with residues of Pb bullets and pellets (shooting range), while the lowest Pb bioaccessibility (0.5%-8.3%) was measured in soils polluted with city waste (including remnants of Pb glazed potsherds and rooftiles, Pb based paint flakes, and Pb sheets). Bioaccessibility of Pb was correlated with pH, organic matter and reactive Fe. These results indicate that soil characteristics play an important role in the oral bioaccessibility of lead in polluted soils. Instead of basing human risk assessment solely on total Pb contents we propose to incorporate in vitro bioaccessibility tests, taking factors such as soil pH, organic matter content and reactive iron content into account. This approach will result in a better insight into the actual risks of Pb polluted soils to children.

Nasal bone length, prenasal thickness, prenasal thickness-to-nasal bone length ratio and prefrontal space ratio in second- and third-trimester fetuses with Down syndrome

OBJECTIVES

To evaluate nasal bone length (NBL), prenasal thickness (PT), prenasal thickness-to-nasal bone length (PT-NBL) ratio and prefrontal space ratio (PFSR) as markers for Down syndrome in the second and third trimesters.

METHODS

NBL, PT, PT-NBL ratio and PFSR were measured retrospectively in stored two-dimensional images or three-dimensional volumes (corrected to the mid-sagittal plane) of fetuses with Down syndrome, which were retrieved from the digital databases of participating units. Measurements were performed on the stored images and volumes by two experienced operators, and the values obtained were compared to our previously reported normal ranges for euploid fetuses in order to assess the detection rates for Down syndrome.

RESULTS

A total of 159 fetuses with Down syndrome were included in the analysis, six of which were excluded because of inadequate available images. Median maternal age was 36.0 years and median gestational age was 23 + 1 weeks. NBL and PT were correlated with gestational age (P < 0.001), but the PT-NBL ratio and PFSR were not. Mean NBL, PT, PT-NBL ratio and PFSR were 4.42 mm, 5.56 mm, 1.26 and 0.34, respectively. The nasal bone was absent in 23 (15.4%) cases. As a marker for Down syndrome, the PT-NBL ratio yielded the highest detection rate (86.2%), followed by PFSR (79.7%), PT (63.4%) and NBL (61.9%). All markers were abnormal in 33.6% of cases, whilst all were normal in 4.7%. At least one of the four markers was abnormal in 95.3%, and either the PT-NBL ratio or PFSR was abnormal in 93.8%. Detection rates were not related to gestational age.

CONCLUSIONS

The PT-NBL ratio and PFSR are robust second- and third-trimester markers for Down syndrome. Both provide high detection rates and are easy to use, as the cut-off for normality is constant throughout gestation. Ltd.

Trends in Serial Measurements of Ultrasound Markers in Second and Third Trimester Down Syndrome Fetuses

OBJECTIVES

To evaluate trends of nasal bone length (NBL), prenasal thickness (PT), nuchal fold (NF), prenasal thickness to nasal bone length (PT-NBL) ratio, and prefrontal space ratio (PFSR), measured serially in second- and third-trimester Down syndrome (DS) fetuses.

METHODS

Prenatal databases were searched for cases of continuing DS pregnancies with serial measurements, taken at least two weeks apart. Trends were plotted on previously reported normal ranges.

RESULTS

Serial measurements were available in 25 Down syndrome fetuses. Median gestational age (GA) was 25 weeks; average number of visits per case was 2.44, with a median interval of 39 days between investigations. In DS fetuses, NBL and PT showed fairly stable trends with gestation. PFSR, but especially NF, had a more unpredictable trend. The PT-NBL ratio was the most stable marker, remaining unchanged in 95% of cases. NBL, PT, and NF showed more deviance from the normal range with advancing gestation, but MoM values remained stable. All but two fetuses had ultrasound markers or structural anomalies, especially heart defects.

CONCLUSIONS

The PT-NBL ratio is the most constant DS marker throughout gestation, following a predictable trend.

Small airway deposition of dornase alfa during exacerbations in cystic fibrosis; a randomized controlled clinical trial

INTRODUCTION

Small airway obstruction is important in the pathophysiology of cystic fibrosis (CF) lung disease. Additionally, many CF patients lose lung function in the long term as a result of respiratory tract exacerbations (RTEs). No trials have been performed to optimize mucolytic therapy during a RTE. We investigated whether specifically targeting dornase alfa to the small airways improves small airway obstruction during RTEs.

METHODS

In a multi-center, double-blind, randomized controlled trial CF patients hospitalized for a RTE and on maintenance treatment with dornase alfa were switched to a smart nebulizer. Patients were randomized to small airway deposition (n = 19) or large airway deposition (n = 19) of dornase alfa for at least 7 days. Primary endpoint was forced expiratory flow at 75% of forced vital capacity (FEF75 ).

MAIN RESULTS

Spirometry parameters improved significantly during admission, but the difference in mean change in FEF75 between treatment groups was not significant: 0.7 SD, P = 0.30. FEF25-75 , FEV1 , nocturnal oxygen saturation and diary symptom scores also did not differ between groups.

CONCLUSIONS

This study did not detect a difference if inhaled dornase alfa was targeted to small versus large airways during a RTE. However, the 95% confidence interval for the change in FEF75 was wide. Further studies are needed to improve the effectiveness of RTE treatment in CF.

Patients with cystic fibrosis have a high carriage rate of non-toxigenic Clostridium difficile

Thirty-year-old observations report frequent asymptomatic Clostridium difficile carriage among cystic fibrosis (CF) patients. In this case-control study, we found more carriers among CF patients than controls (47% versus 11%), but most strains carried by CF patients were non-toxigenic (77% versus 17%). Among CF patients, carriers were younger, with more severe pulmonary disease than non-carriers. Strains belonged to multiple PCR-ribotypes, suggesting that these CF patients did not acquire strains from each other.

Locally advanced rectal cancer: is diffusion weighted MRI helpful for the identification of complete responders (ypT0N0) after neoadjuvant chemoradiation therapy?

OBJECTIVES

To determine retrospectively the additional value of DWI-MRI toT2-MRI for predicting complete response (ypT0N0 = CR) after chemoradiation-therapy (CRT) in locally advanced rectal cancer.

METHODS

Seventy locally advanced rectal cancer patients underwent CRT followed by restaging MRI and resection. Two readers with different experience levels independently scored T2 images for CR and, in a second reading, combined T2 and DWI. A 5-point confidence-level score was used to generate ROC curves. Areas under the ROC curves (AUC) and interobserver agreement were compared for both readings. Histology served as reference standard.

RESULTS

The interobserver agreement increased after addition of DWI from 0.35 to 0.58 but the AUC improved only for the experienced reader (0.77 to 0.89, p = 0.005 vs. 0.74 to 0.70, p > 0.05). Sensitivity and NPV improved from 20-30 % to 40-70 %, respectively 88 % to 91-95 %. Specificity and PPV improved only for the experienced reader (87 to 93 % respectively 27 to 63 %).

CONCLUSION

Adding DWI to T2-MRI improves consistency between readers and has potential to improve readers' accuracy dependent on his/her experience. DWI could be of additional value, particularly in ruling out CR (high NPV), but considering the sub-optimal PPV one should be cautious about relying solely on MRI for the clinical decision to offer a wait-and-see strategy.

Premaxillary protrusion assessment by the maxilla-nasion-mandible angle in fetuses with facial clefts

OBJECTIVE

The aim of the study was to measure the degree of premaxillary protrusion in fetuses with orofacial clefts of various severities.

METHODS

The maxilla-nasion-mandible (MNM) angle was measured retrospectively on by multiplanar corrected volumes. Sixty-two fetuses with orofacial clefts and known outcome volumes of the fetal head were available.

RESULTS

In 48 of the 62 cases, the MNM angle could be measured [mean gestational age 23 (range, 18-30) weeks]. The mean MNM angle was normal in all nine cases with cleft lip and intact alveolar ridge (15.2°; range, 12.5°- 16.9°). In 24 cases with unilateral cleft lip with or without cleft palate (UCL/P), the mean MNM angle was 20.0° (range, 13.3-26.2°), being above the 95th percentile in 79% (n = 19) and normal in 21% (n = 5). In 14 bilateral cleft lip and palate (BCL/P) cases, the mean MNM angle was 26.5° (range, 19.2°-33.7°) and above the 95th percentile in all cases. There was no difference in MNM angle between isolated clefts and clefts associated with other anomalies. In one case with a Tessier 4 cleft, the MNM angle was above the 95th percentile (25.2°).

CONCLUSION

The premaxilla tends to protrude in both BCL/P as UCL/P cases. The degree of protrusion varies greatly, especially in the BCL/P group.

Recent decrease in the prevalence of congenital heart defects in Europe

OBJECTIVES

To examine trends in the prevalence of congenital heart defects (CHDs) in Europe and to compare these trends with the recent decrease in the prevalence of CHDs in Canada (Quebec) that was attributed to the policy of mandatory folic acid fortification.

STUDY DESIGN

We used data for the period 1990-2007 for 47 508 cases of CHD not associated with a chromosomal anomaly from 29 population-based European Surveillance of Congenital Anomalies registries in 16 countries covering 7.3 million births. We estimated trends for all CHDs combined and separately for 3 severity groups using random-effects Poisson regression models with splines.

RESULTS

We found that the total prevalence of CHDs increased during the 1990s and the early 2000s until 2004 and decreased thereafter. We found essentially no trend in total prevalence of the most severe group (group I), whereas the prevalence of severity group II increased until about 2000 and decreased thereafter. Trends for severity group III (the most prevalent group) paralleled those for all CHDs combined.

CONCLUSIONS

The prevalence of CHDs decreased in recent years in Europe in the absence of a policy for mandatory folic acid fortification. One possible explanation for this decrease may be an as-yet-undocumented increase in folic acid intake of women in Europe following recommendations for folic acid supplementation and/or voluntary fortification. However, alternative hypotheses, including reductions in risk factors of CHDs (eg, maternal smoking) and improved management of maternal chronic health conditions (eg, diabetes), must also be considered for explaining the observed decrease in the prevalence of CHDs in Europe or elsewhere.