Clinical implementation of first trimester screening for congenital heart defects.

OBJECTIVE: To examine the feasibility and performance of implementing a standardized fetal cardiac scan at the time of a routine first-trimester ultrasound scan. METHOD: A retrospective, single-center study in an unselected population between March 2021 and July 2022. A standardized cardiac scan protocol consisting of a four-chamber and 3-vessel trachea view with color Doppler was implemented as part of the routine first-trimester scan. Sonographers were asked to categorize the fetal heart anatomy. Data were stratified into two groups based on the possibility of evaluating the fetal heart. The influence of maternal and fetal characteristics and the detection of major congenital heart disease were investigated. RESULTS: A total of 5083 fetuses were included. The fetal heart evaluation was completed in 84.9%. The proportion of successful scans increased throughout the study period from 76% in the first month to 92% in the last month. High maternal body mass index and early gestational age at scan significantly decreased the feasibility. The first-trimester detection of major congenital heart defects was 7/16, of which four cases were identified by the cardiac scan protocol with no false-positive cases. CONCLUSION: First-trimester evaluation of the fetal heart by a standardized scan protocol is feasible to implement in daily practice. It can contribute to the earlier detection of congenital heart defects at a very low false positive rate.

Does group size matter during collaborative skills learning? A randomised study.

BACKGROUND: Collaborative skills learning in the form of dyad learning compared with individual learning has been shown to lead to non-inferior skills retention and transfer. However, we have limited knowledge on which learning activities improve collaborative skills training and how the number of collaborators may impact skills transfer. We explored the effects of skills training individually, in dyads, triads or tetrads on learning activities during training and on subsequent skills transfer. METHODS: In a randomised, controlled study, participants completed a pre-post-transfer-test set-up in groups of one to four. Participants completed 2 hours of obstetric ultrasound training. In the dyad, triad and tetrad group participants took turns actively handling the ultrasound probe. All performances were rated by two blinded experts using the Objective Structured Assessment of Ultrasound Skills (OSAUS) scale and a Global Rating Scale (GRS). All training was video recorded, and learning activities were analysed using the Interactive-Constructive-Active-Passive (ICAP) framework. RESULTS: One hundred one participants completed the simulation-based training, and ninety-seven completed the transfer test. Performance scores improved significantly from pre- to post-test for all groups (p < 0.001, ηp2 = 0.55). However, group size did not affect transfer test performance on OSAUS scores (p = 0.13, ηp2 = 0.06) or GRS scores (p = 0.23, ηp2 = 0.05). ICAP analyses of training activities showed that time spent on non-learning and passive learning activities increased with group size (p < 0.001, ηp2 = 0.31), whereas time spent on constructive and interactive learning activities was constant between groups compared with singles (p < 0.001, ηp2 = 0.72). CONCLUSION: Collaborative skills learning in groups of up to four did not impair skills transfer despite less hands-on time. This may be explained by a compensatory shift towards constructive and interactive learning activities that outweigh the effect of shorter hands-on time.

Refractory Fetal Supraventricular Tachycardia with Hydrops Successfully Converted by Intraperitoneal Flecainide in the Fetus: A Case Report.

INTRODUCTION: Supraventricular tachycardia is the most common fetal tachyarrhythmia and if persistent often associated with fetal hydrops which can cause intrauterine and neonatal death. CASE PRESENTATION: We present a case of early second trimester supraventricular tachycardia in a hydropic fetus, initially refractory to transplacental treatment. CONCLUSION: The supraventricular tachycardia was successfully treated when supplemented with intraperitoneal flecainide in the fetus.

Fetal rotation during vacuum extractions for prolonged labor: a prospective cohort study.

INTRODUCTION: The aim of the study was to investigate fetal head rotation during vacuum extraction. MATERIAL AND METHODS: We conducted a prospective cohort study from November 2013 to July 2016 in seven European hospitals. Fetal head position was determined with transabdominal or transperineal ultrasound and categorized as occiput anterior (OA), occiput transverse (OT) or occiput posterior (OP) position. Main outcome was the proportion of fetuses rotating during vacuum extraction. Secondary outcomes were conversion of delivery method, duration of vacuum extraction, umbilical artery pH <7.10 and agreement between clinical and ultrasound assessments. RESULTS: The study population comprised 165 women. During vacuum extraction 117/119 (98%) remained in OA and two fetuses rotated to OP position. Rotation from OT to OA position occurred in 14/19 (74%) and to OP position in 5/19 (26%). Rotation from OP to OA position occurred in 15/25 (60%), and 10/25 (40%) fetuses remained in OP position. Delivery information was missing in two cases. The conversion rate from vacuum extraction to cesarean section or forceps was 10% in the OA group vs. 23% in the non-OA group; p < 0.05. The estimated duration of vacuum extraction was significantly shorter in OA fetuses, 7 min vs. 10 min (log rank test p < 0.01). There was no significant difference in umbilical artery pH < 7.10 between OA and non-OA position. Cohens Kappa of agreement between clinical and ultrasound assessments was 0.42 (95% CI 0.26-0.57). CONCLUSION: Most fetuses in OP or OT positions rotated to OA position during vacuum extraction, but the proportion of failed vacuum extractions remained high.

Sonographic prediction of outcome of vacuum deliveries: a multicenter, prospective cohort study.

BACKGROUND: Safe management of the second stage of labor is of great importance. Unnecessary interventions should be avoided and correct timing of interventions should be focused. Ultrasound assessment of fetal position and station has a potential to improve the precision in diagnosing and managing prolonged or arrested labors. The decision to perform vacuum delivery is traditionally based on subjective assessment by digital vaginal examination and clinical expertise and there is currently no method of objectively quantifying the likelihood of successful delivery. Prolonged attempts at vacuum delivery are associated with neonatal morbidity and maternal trauma, especially so if the procedure is unsuccessful and a cesarean is performed. OBJECTIVE: The aim of the study was to assess if ultrasound measurements of fetal position and station can predict duration of vacuum extractions, mode of delivery, and fetal outcome in nulliparous women with prolonged second stage of labor. STUDY DESIGN: We performed a prospective cohort study in nulliparous women at term with prolonged second stage of labor in 7 European maternity units from 2013 through 2016. Fetal head position and station were determined using transabdominal and transperineal ultrasound, respectively. Our preliminary clinical experience assessing head-perineum distance prior to vacuum delivery suggested that we should set 25 mm for the power calculation, a level corresponding roughly to +2 below the ischial spines. The main outcome was duration of vacuum extraction in relation to ultrasound measured head-perineum distance with a predefined cut-off of 25 mm, and 220 women were needed to discriminate between groups using a hazard ratio of 1.5 with 80% power and alpha 5%. Secondary outcomes were delivery mode and umbilical artery cord blood samples after birth. The time interval was evaluated using survival analyses, and the outcomes of delivery were evaluated using receiver operating characteristic curves and descriptive statistics. Results were analyzed according to intention to treat. RESULTS: The study population comprised 222 women. The duration of vacuum extraction was shorter in women with head-perineum distance ≤25 mm (log rank test <0.01). The estimated median duration in women with head-perineum distance ≤25 mm was 6.0 (95% confidence interval, 5.2-6.8) minutes vs 8.0 (95% confidence interval, 7.1-8.9) minutes in women with head-perineum distance >25 mm. The head-perineum distance was associated with spontaneous delivery with area under the curve 83% (95% confidence interval, 77-89%) and associated with cesarean with area under the curve 83% (95% confidence interval, 74-92%). In women with head-perineum distance ≤35 mm, 7/181 (3.9%) were delivered by cesarean vs 9/41 (22.0%) in women with head-perineum distance >35 mm (P <.01). Ultrasound-assessed position was occiput anterior in 73%. Only 3/138 (2.2%) fetuses in occiput anterior position and head-perineum distance ≤35 mm vs 6/17 (35.3%) with nonocciput anterior position and head-perineum distance >35 mm were delivered by cesarean. Umbilical cord arterial pH <7.10 occurred in 2/144 (1.4%) women with head-perineum distance ≤35 mm compared to 8/40 (20.0%) with head-perineum distance >35 mm (P < .01). CONCLUSION: Ultrasound has the potential to predict labor outcome in women with prolonged second stage of labor. The information obtained could guide whether vacuum delivery should be attempted or if cesarean is preferable, whether senior staff should be in attendance, and if the vacuum attempt should be performed in the operating theater.

YKL-40 and genetic status of CHI3L1 in a large group of asthmatics.

BACKGROUND: Studies have shown a relationship between asthma, serum YKL-40, and the single nucleotide polymorphism (SNP) (-131 C/G, rs4950928) in the CHI3L1 gene that codes for YKL-40. However, the findings differ. We studied the relationship between clinical asthma phenotypes, serum YKL-40, and SNP (-131 C/G, rs4950928). METHODS: In this study, 1,137 patients with asthma, 415 with rhinitis only, and 275 non-asthmatic controls were included. Assessment included a clinical interview concerning the diagnosis of asthma, severity of asthma, and asthma treatment as well as clinical tests to assess asthma and rhinitis. Serum YKL-40 was measured, and genotyping for the SNP (-131 C/G) was conducted. RESULTS: No significant difference in the serum concentration of YKL-40 was found between patients with asthma, patients with rhinitis, and non-asthmatic controls; however, YKL-40 was increased in patients with severe asthma. No association was found between the SNP (-131 C/G rs4950982) and the risk of having asthma (odds ratio = 0.90, p=0.4). Higher levels of serum YKL-40 were found in all subjects when comparing CC genotype to CG and GG genotypes (45 µg/L vs. 32 µg/L and 19 µg/L, p<0.0001). CONCLUSION: There was no association between polymorphisms of SNP (-131 C/G) and asthma. The highest serum YKL-40 concentrations were seen in severe asthmatics. Individuals with less severe asthma showed a smaller difference against controls, limiting its clinical usefulness. More research is needed to clarify the relationship between different asthma phenotypes, YKL-40, and CHI3L1.

Airway hyperresponsiveness and development of lung function in adolescence and adulthood.

BACKGROUND: Long-term longitudinal studies of lung function from childhood to adulthood are important in linking our understanding of childhood risk factors to adult disease. Airway hyperresponsiveness has been shown to independently affect lung function growth in studies of adolescence. The objective of the study was to test the hypothesis that airway hyperresponsiveness has an independent deleterious effect on lung function in adolescence that extends into adulthood. METHODS: A random population sample (n = 983) aged 7-17 from Copenhagen was followed longitudinally for 20 years with four examinations. RESULTS: A total of 780 (79.3%) subjects contributed with lung function measurements and bronchial provocation testing. Among these, 170 (21.8%) had airway hyperresponsiveness at one examination or more during the study period. There was no difference in initial FEV1 levels between subjects with and without airway hyperresponsiveness. In a repeated measures regression model with adjustment for asthma and smoking, airway hyperresponsiveness was independently associated with reduced rates of growth in lung function in both sexes of 23 ml/year. Reduced growth rates resulted in deficits in maximal attained level of lung function at age 18, which persisted throughout the follow-up until the last examination at age 27-37 years. CONCLUSION: Airway hyperresponsiveness has an independent deleterious effect on lung function development from 7 to 37 years resulting in a lower maximal attained lung function and persistent deficits in lung function in adulthood.

Risk of chronic bronchitis in twin pairs discordant for smoking.

BACKGROUND: It is well known that smoking is a major risk factor for lung disease and respiratory symptoms. We examined the association between smoking and the risk of chronic bronchitis in a large twin sample. METHODS: In a population-based questionnaire study of 13,649 twins, aged 50-71 years, from the Danish Twin Registry, we identified 1,146 twin pairs, discordant for a lifetime history smoking. We performed co-twin control analysis to examine the impact of smoking on the risk of chronic bronchitis. RESULTS: The prevalence of chronic bronchitis was 9.7 %. In the total sample, high age, living without a spouse, and smoking remained statistically significant predictors with an up to tenfold increased risk of chronic bronchitis in the heaviest smokers compared with never-smokers, after multivariate adjustment. Among twin pairs discordant for smoking, chronic bronchitis was significantly more common in the smoking twin compared with the nonsmoking co-twin. There was no differential effect of smoking on the risk of chronic bronchitis in monozygotic and dizygotic twins. CONCLUSIONS: The risk of chronic bronchitis increases with age and increasing tobacco consumption. The results indicate a direct relationship between smoking and development of chronic bronchitis, but other environmental factors, such as exposure to household smoking in childhood and living without a spouse, also play a role.

Asthma patients who smoke have signs of chronic airflow limitation before age 45.

BACKGROUND: The frequency of smokers among asthma patients often mirrors the frequency of smokers among healthy individuals. Smoking has been shown to increase the lung function decline in adult asthma patients and change the composition of the bronchial inflammation. OBJECTIVE: To examine the consequences of smoking in a large cohort of young asthma patients. METHODS: Seven hundred ninety-three asthma patients, aged 14 to 44, were examined using lung function measurements, bronchial provocations, clinical interviews, and questionnaires. RESULTS: Forty-five percent of participants were smokers; smokers had significantly lower forced expiratory volume in one second (FEV(1)), FEV(1) in percent of predicted value (FEV(1)% pred), and FEV(1)/forced vital capacity (FVC) values compared with nonsmokers, and there was a dose-response relationship between tobacco exposure and these lung function measures. Smoking seemingly affected the FEV(1) growth already in adolescence, and before the age of 45, significantly more smokers than nonsmokers had signs of airflow limitation, with FEV(1)/FVC ratios below 0.70. Smokers had more asthma symptoms despite receiving inhaled corticosteroid (ICS) treatment as frequently as did nonsmokers. CONCLUSION: The additive effect of smoking on lung function decline in asthma patients is detectable at early ages and leads to signs of airflow limitation before the age of 45 years.

The effect of generalist and specialist care on quality of life in asthma patients with and without allergic rhinitis.

BACKGROUND: Treatment of asthma and rhinitis patients is often provided by both generalists (GPs) and specialists (SPs). Studies have shown differences in clinical outcomes of treatment between these settings. The aim of this study was to evaluate the effect of GP and SP care on health-related quality of life (HRQoL). MATERIALS AND METHODS: Three hundred and eight asthma and allergic rhinitis patients randomized to 3 years' treatment by an SP or GP were examined at baseline and at study completion. At both examinations, the HRQoL was measured with the Standardized Asthma Quality of Life Questionnaire (AQLQ) and the Rhinitis Quality of Life Questionnaire (RQLQ). RESULTS: In the SP care, a significant improvement from baseline was found in HRQoL for both AQLQ total scores (6.19 +/- 0.1 vs. 6.44 +/- 0.1, respectively; p < 0.001) and RQLQ total scores (0.80 +/- 0.1 vs. 0.58 +/- 0.1, respectively; p <0.01). Patients in the GP care setting experienced no change in HRQoL total scores during the study. However, improvements were found predominantly in patients with concomitant rhinitis. Although no change in AQLQ was found in the GP setting in this group with double disease, an association between change in RQLQ and AQLQ was found (r = -0.245, p < 0.05, and r = -0.324, p < 0.001, respectively). CONCLUSION: The results provide evidence that compared with GP care, SP care leads to an improvement in both asthma and rhinitis quality of life. This is especially pronounced in patients with concomitant asthma and rhinitis and supports the guidelines recommending that SPs should monitor patients with complicated disease.

[Evaluation of walk-in lung function service for smokers in Copenhagen--a 1-year study]. / Walk-in ambulant lungefunktionsservice for rygere i København--etårsopgørelse.

BACKGROUND: Early prevention of COPD and immediate consultation about tobacco cessation is a major issue in respiratory medicine. AIM: To evaluate if a community-based walk-in lung function service, either in a clinic or a shopping mall, could result in early detection of COPD. Early detection would facilitate prevention. MATERIALS AND METHODS: In an area with 1.5 mill inhabitants, a walk-in lung function service opened in 2005/06 once a month for 3 hours at a clinic and on two full days in a mall. The staff consisted of two respiratory nurses and one chest physician. The nurses informed all participants about their lung function level and all received a preventive talk about tobacco consumption. Those with signs of COPD spoke with the doctor immediately. RESULTS: A total of 1169 subjects, 59% women, with a mean (SD) age of 60 years (15), visited the walk-in services, 602 (52%) of whom visited the walk-in service at the clinic. Among the participants, 826 (71%) were smokers (n=452) or former smokers (n=374). The mean tobacco consumption was 32 (18) packs a year. We found that more current smokers visited the walk-in service at the clinic (45% versus 33%), whereas more ex-smokers visited the lung function service at the mall (38% versus 25%) (p < 0.01). The mean tobacco consumption was 32 (18) packs a year, with a difference between those visiting the mall and the clinic (32 (20) versus 23 (16), p<0.05). Among smokers, 54% had normal lung function, 15% had signs of airway obstruction, whereas 31% had developed moderate to severe COPD. CONCLUSION: Despite free medical access, more that one thirds had signs of airway obstruction. As all were informed about tobacco cessation, a walk-in service in a clinic and not a supermarket is most cost effective.