SARS-CoV-2 vaccination modelling for safe surgery to save lives : data from an international prospective cohort study

Background: Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods: The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18-49, 50-69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results: NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. Conclusion: As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population.Peer reviewe

Role of prenatal magnetic resonance imaging in fetuses with isolated mild or moderate ventriculomegaly in the era of neurosonography: international multicenter study

Objectives To assess the role of fetal magnetic resonance imaging (MRI) in detecting associated anomalies in fetuses presenting with mild or moderate isolated ventriculomegaly (VM) undergoing multiplanar ultrasound evaluation of the fetal brain. Methods This was a multicenter, retrospective, cohort study involving 15 referral fetal medicine centers in Italy, the UK and Spain. Inclusion criteria were fetuses affected by isolated mild (ventricular atrial diameter, 10.0–11.9 mm) or moderate (ventricular atrial diameter, 12.0–14.9 mm) VM on ultrasound, defined as VM with normal karyotype and no other additional central nervous system (CNS) or extra‐CNS anomalies on ultrasound, undergoing detailed assessment of the fetal brain using a multiplanar approach as suggested by the International Society of Ultrasound in Obstetrics and Gynecology guidelines for the fetal neurosonogram, followed by fetal MRI. The primary outcome of the study was to report the incidence of additional CNS anomalies detected exclusively on prenatal MRI and missed on ultrasound, while the secondary aim was to estimate the incidence of additional anomalies detected exclusively after birth and missed on prenatal imaging (ultrasound and MRI). Subgroup analysis according to gestational age at MRI (< 24 vs ≥ 24 weeks), laterality of VM (unilateral vs bilateral) and severity of dilatation (mild vs moderate VM) were also performed. Results Five hundred and fifty‐six fetuses with a prenatal diagnosis of isolated mild or moderate VM on ultrasound were included in the analysis. Additional structural anomalies were detected on prenatal MRI and missed on ultrasound in 5.4% (95% CI, 3.8–7.6%) of cases. When considering the type of anomaly, supratentorial intracranial hemorrhage was detected on MRI in 26.7% of fetuses, while polymicrogyria and lissencephaly were detected in 20.0% and 13.3% of cases, respectively. Hypoplasia of the corpus callosum was detected on MRI in 6.7% of cases, while dysgenesis was detected in 3.3%. Fetuses with an associated anomaly detected only on MRI were more likely to have moderate than mild VM (60.0% vs 17.7%; P < 0.001), while there was no significant difference in the proportion of cases with bilateral VM between the two groups (P = 0.2). Logistic regression analysis showed that lower maternal body mass index (adjusted odds ratio (aOR), 0.85 (95% CI, 0.7–0.99); P = 0.030), the presence of moderate VM (aOR, 5.8 (95% CI, 2.6–13.4); P < 0.001) and gestational age at MRI ≥ 24 weeks (aOR, 4.1 (95% CI, 1.1–15.3); P = 0.038) were associated independently with the probability of detecting an associated anomaly on MRI. Associated anomalies were detected exclusively at birth and missed on prenatal imaging in 3.8% of cases. Conclusions The incidence of an associated fetal anomaly missed on ultrasound and detected only on fetal MRI in fetuses with isolated mild or moderate VM undergoing neurosonography is lower than that reported previously. The large majority of these anomalies are difficult to detect on ultrasound. The findings from this study support the practice of MRI assessment in every fetus with a prenatal diagnosis of VM, although parents can be reassured of the low risk of an associated anomaly when VM is isolated on neurosonography

Gravidanza multipla e malformazioni

Il diffondersi delle tecniche di procreazione medicalmente assistita (PMA) ha portato ad un aumento dell’incidenza delle gravidanze gemellari, rendendo necessaria la discussione della maggiore frequenza di malformazioni congenite documentata nei nati da gravidanza plurima. Contrariamente rispetto a quanto siamo abituati a credere, i gemelli non sono necessariamente identici, ma possono differire tra loro per anomalie congenite e/o genetiche: si definiscono concordanti i gemelli che presentano la stessa malformazione, mentre sono discordanti se uno solo dei gemelli presenta un’anomalia congenita, oppure se entrambi hanno anomalie congenite, ma distinguibili sotto il profilo eziopatogenetico. Le anomalie di più comune riscontro nei gemelli sono le anomalie cardiache, del sistema nervoso centrale e dell’apparato gastroenterico. Gli stressi gemelli monocoriali possono presentare cariotipo discordante per anomalie cromosomiche (gemelli eterocarionti) o malattie monogeniche (gemelli eteroallelici). I progressi della chirurgia pediatrica nell’ambito delle tecniche di separazione dei gemelli congiunti, in associazione all’uso estensivo dell’ecografia ostetrica nel primo trimestre, impongono agli ecografisti ostetrici la definizione diagnostica precoce dei casi di gemelli congiunti, così da poter fornire ai futuri genitori gli strumenti più idonei per una scelta consapevole circa la prosecuzione di una gravidanza. Le informazioni disponibili in letteratura circa le anomalie congenite nei gemelli sono, purtroppo, ad oggi, frammentarie. Pertanto gli studiosi esperti hanno il dovere, nei casi di anomalie genetiche o fenotipiche in gravidanza gemellare, di pubblicare, nel medesimo report, i risultati delle analisi genetiche, degli esami istologici delle placente, delle eventuali autopsie o dell’esame clinico postnatale, così da contribuire, in modo concreto, ai futuri studi sulle anomalie nelle gravidanze gemellari

Three-dimensional sonography of unilateral Tessier number 7 cleft in a mid-trimester fetus.

We herein report the case of a primigravida, 29-year-old woman who was referred for an anomaly scan at 21 weeks' gestation. There were no specific risk factors for fetal malformations and the pregnancy had been unremarkable. First-trimester screening by nuchal translucency measurement and biochemistry suggested a very low risk of chromosomal aberrations

Fetal cerebellar damage in fetuses with severe anemia undergoing intrauterine transfusions

Objective: To evaluate radiologic findings and outcomes of cerebellar injuries in fetuses with severe anemia due to RhD alloimmunization undergoing intrauterine transfusions.Methods: Imaging of multiplanar neurosonography and magnetic resonance imaging (MRI) were reviewed. Pregnancy outcomes were recorded.Results: Cerebellar injuries were identified after the first intravascular transfusion in four fetuses. Two of these cases were previously reported. The median hemoglobin concentration was 2.1 g/dL. Prenatal neurosonography identified an echogenic collection involving the cerebellum suggestive for hemorrhage in three cases. A progressive hypoplasia of a hemisphere was demonstrated at follow-up examination in one of these cases. Hypoplasia of a cerebellar hemisphere was seen in the fourth fetus. Ultrasound diagnosis was confirmed by prenatal MRI in two cases. In the third case, the postnatal MRI showed as additional finding vermian involvement. One pregnancy was terminated and autopsy confirmed the presence of infratentorial hemorrhage. The remaining infants were delivered alive. At time of writing, a truncal ataxia was diagnosed in the child with vermian hypoplasia, while the other children have met all age-appropriate milestones.Conclusions: A severe anemia seems to put the fetus at risk of cerebellar damage, despite successful intravascular transfusion

Prenatal diagnosis of congenital heart defects and voluntary termination of pregnancy

BACKGROUND: The prenatal diagnosis of an isolated congenital heart defect is a matter of concern for parents. The decision of whether to terminate the pregnancy according to the different types of congenital heart defects has not been investigated yet.OBJECTIVE: This study aimed to evaluate the frequency of voluntary termination of pregnancy after the prenatal diagnosis of a congenital heart defect in a tertiary care center.STUDY DESIGN: This was a retrospective study of patients who were referred to our center from January 2013 to December 2019, underwent fetal echocardiography, and were counseled by a perinatologist and a pediatric cardiologist. The following data were collected: prenatal diagnosis, including genetic testing; gestational age at diagnosis; and outcome of pregnancy. The diagnoses were stratified retrospectively according to the type of congenital heart defect and its severity (low complexity, moderate complexity, and high complexity) by a perinatologist and a pediatric cardiologist.RESULTS: Of 704 women who received a diagnosis of fetal congenital heart defect, 531 (75.4%) were seen before 23 weeks' gestation, which is the upper limit imposed for the termination of pregnancy by the Italian legislation. Congenital heart defects were apparently isolated in 437 of 531 cases (82.3%). Overall, 108 of 531 patients (20.3%) requested a termination of pregnancy. The rate of termination of pregnancy was found to vary according to the severity of congenital heart defects: low complexity, 0%; moderate complexity, 12.1%, and high complexity, 33.2% (P&lt;.001). The presence or absence of associated anomalies or the ethnicity of the couples was not found to have an influence on women's decisions.CONCLUSION: In our population, the decision to terminate a pregnancy after the diagnosis of a fetal congenital heart defect is influenced by the surgical complexity of the congenital heart defect itself. However, most patients, including those with the most severe forms of congenital heart defect, decided to continue the pregnancy

Agriculture in Marginal Areas: Reintroduction of Rye and Wheat Varieties for Breadmaking in the Antrona Valley

In marginal lands, cereal landraces continue to be important in agricultural production, whereas hybrids lose their competitive advantage. In this context, selection for adaptation to each environment is particularly important in crops grown under unfavourable conditions, e.g., mountain areas. In this work, from a panel of traditional and modern varieties, mixtures and evolutionary populations, a randomised block experiment was established to select the most productive and suitable wheat and rye varieties specific for the Antrona Valley. The nutritional analysis of each flour was carried out. The results obtained in two years of varietal comparison suggested that rye is more suitable than wheat for growing in this environment: Alpina rye showed the highest yield/m2 and the highest ash content (1.87% &plusmn; 0.03%; p &lt; 0.05) compared to other varieties, indicating it as suitable for the baking process. Among wheats, San Pastore showed the highest number of ears/m2 (411 and 350; p &lt; 0.05) compared to others. However, in a context of climate change, the cultivation of Solibam could ensure yield stability, thanks to the high variability within the evolutionary population. Overall, our results demonstrated the possible reintroduction of the cereal supply chain in the Valley and the resumption of the historic rye bread production

Agriculture in Marginal Areas: Reintroduction of Rye and Wheat Varieties for Breadmaking in the Antrona Valley

In marginal lands, cereal landraces continue to be important in agricultural production, whereas hybrids lose their competitive advantage. In this context, selection for adaptation to each environment is particularly important in crops grown under unfavourable conditions, e.g., mountain areas. In this work, from a panel of traditional and modern varieties, mixtures and evolutionary populations, a randomised block experiment was established to select the most productive and suitable wheat and rye varieties specific for the Antrona Valley. The nutritional analysis of each flour was carried out. The results obtained in two years of varietal comparison suggested that rye is more suitable than wheat for growing in this environment: Alpina rye showed the highest yield/m2 and the highest ash content (1.87% ± 0.03%; p 2 (411 and 350; p < 0.05) compared to others. However, in a context of climate change, the cultivation of Solibam could ensure yield stability, thanks to the high variability within the evolutionary population. Overall, our results demonstrated the possible reintroduction of the cereal supply chain in the Valley and the resumption of the historic rye bread production