Antenatal findings and early postnatal outcomes in pregnancies with trisomy 21: a 10-year retrospective review at a tertiary centre

Objective To examine the antenatal imaging features, intrapartum findings and early postpartum course of pregnancies with trisomy 21 (T21). Design Ten-year retrospective review Setting A tertiary hospital in the United Kingdom Population Women with a pregnancy affected by T21, who did not have a termination. Methods Women with pregnancies diagnosed with T21 on: antenatal karyotyping; karyotyping of post-mortem tissue and postnatal karyotype samples, from February 2010-2020. Main Outcome Measures Antenatal imaging findings, fetal growth restriction (FGR), birthweight, mode of delivery, and early neonatal outcomes. Results Seventy-six women with a fetus affected by T21 were identified. There were 6 intrauterine deaths, and 70 livebirths. Thirty-eight (50%) had an antenatal diagnosis and twenty-five (33%) had a suspected diagnosis but declined further testing. The diagnosis was unanticipated in 13 (17%). Cardiac anomalies (n=27) were the most common antenatal anomaly. Doppler abnormalities were apparent in 48/73 (68%). Eighteen (25.7%) had ultrasound evidence of FGR. The majority delivered by Caesarean section, and 21.4% of babies weighed below the 3rd percentile at delivery. Fifty-eight (82%) were admitted to the neonatal unit. Forty-three (61%) required respiratory support and fifty-five (78%) either needed naso-gastric feeding or were nil by mouth. Mean PAPP-A values were significantly lower in cases with abnormal Dopplers, FGR, congenital anomalies and with a birthweight below the 10th percentile. Conclusions Fetuses with T21 have high rates of placental insufficiency. FGR and Doppler abnormalities are common. Postnatally, the majority will require respiratory and feeding support. Antenatal counselling and protocols should reflect these risks. Funding None

Successful Treatment with Crushed Sofosbuvir/Velpatasvir of a Patient with Decompensated Cirrhosis C and Thrombocytopenia

A 36-year-old woman with decompensated liver cirrhosis type C was referred to our hospital to receive antiviral treatment for hepatitis C virus (HCV). She had been diagnosed with intractable epilepsy and cerebral palsy at birth and was managed by central venous nutrition and nasal gastric feeding. At age 34 years, she was diagnosed with thrombocytopenia, probably associated with HCV infection. She showed refractory ascites for several months and was therefore administered crushed sofosbuvir/velpatasvir tablets via a nasal gastric tube. Her HCV infection was successfully eradicated, her ascites disappeared, and thrombocytopenia improved with a marked decrease in platelet-associated IgG.

The efficacy and safety of prokinetics in critically ill adults receiving gastric feeding tubes: A systematic review and meta-analysis

Background Intolerance to gastric feeding tubes is common among critically ill adults and may increase morbidity. Administration of prokinetics in the ICU is common. However, the efficacy and safety of prokinetics are unclear in critically ill adults with gastric feeding tubes. We conducted a systematic review to determine the efficacy and safety of prokinetics for improving gastric feeding tube tolerance in critically ill adults. Methods Randomized controlled trials (RCTs) were identified by systematically searching the Medline, Cochrane and Embase databases. Two independent reviewers extracted the relevant data and assessed the quality of the studies. We calculated pooled relative risks (RRs) for dichotomous outcomes and the mean differences (MDs) for continuous outcomes with the corresponding 95% confidence intervals (CIs). We assessed the risk of bias using the Cochrane risk-of-bias tool and used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to rate the quality of the evidence. Results Fifteen RCTs met the inclusion criteria. A total of 10 RCTs involving 846 participants were eligible for the quantitative analysis. Most studies (10 of 13, 76.92%) showed that prokinetics had beneficial effects on feeding intolerance in critically ill adults. In critically ill adults receiving gastric feeding, prokinetic agents may reduce the ICU length of stay (MD -2.03, 95% CI -3.96, -0.10; P = 0.04; low certainty) and the hospital length of stay (MD -3.21, 95% CI -5.35, -1.06; P = 0.003; low certainty). However, prokinetics failed to improve the outcomes of reported adverse events and all-cause mortality. Conclusion As a class of drugs, prokinetics may improve tolerance to gastric feeding to some extent in critically ill adults. However, the certainty of the evidence suggesting that prokinetics reduce the ICU or hospital length of stay is low. Prokinetics did not significantly decrease the risks of reported adverse events or all-cause mortality among critically ill adults.

Introducer Percutaneous Endoscopic Gastrostomy in Palliative Care of Patients with Esophageal Cancer

In the treatment of esophageal cancer and palliative care, nutritional status plays an important role in the patients’ tolerance of treatment, affects the quality of life, and outcomes. Alimentation in such patients can be achieved by enteral or parenteral nutrition but the enteral route is the preferring option. Pre-pyloric feeding is easier and may result in greater nutritional benefits than post-pyloric feeding. Gastrostomy is the conventional option for intra-gastric feeding, hydration, and drug administration. Percutaneous endoscopic gastrostomy (PEG) is a minimally invasive procedure and is currently the procedure of choice. Two PEG techniques are clinically used worldwide: pull and push or introducer method. The pull-type technique is the most commonly used method, but the concerning point is that the implantation of esophageal cancer cells into the gastrostomy stroma. The introducer method is a safe alternative and effective technique for enteral feeding to the stomach with the avoidance of cancer cells seeding.

Autobiographical Memory and End-of-Life Treatment Preferences in China

In this mixed-methods study of religious/cultural beliefs and end-of-life treatment preferences in China, we surveyed 1,085 mainland Chinese people aged 18 or above online. We assessed the effects of past experience with dying people they have known and their own end-of-life treatment preferences in two hypothetical terminal illness vignettes. We found that respondents who knew or visited someone at the end of their lives were somewhat less likely to choose aggressive treatment for themselves in a lung cancer scenario (25% compared to 33%, p=.013). However, there was less difference in an Alzheimer’s disease scenario, with a choice to use a gastric feeding tube or not (39% compared to 42%, p=.262). Open-ended responses indicate that people refer to these past experiences as a reference in making end-of-life decisions for themselves. This study provides empirical evidence that autobiographical memory has a directive function that individuals call on to inform future behaviors.