Motherisk Program in Canada  June Seek Choi, M.D., PhD.  The Korean Motherisk Program,  Div. of Maternal-Fetal Medicine,  ...
The Hospital for Sick Children
The Hospital for Sick Children
The Hospital for Sick Children
Contents• Organization Chart• Motherisk Program (Clinic and Call Center)• Laboratory Studies in Motherisk• Studies in Canada
Organization Chart
Organization Chart (1)• Dr. Gideon Koren- Director of Motherisk• Dr. Ito Shinya- Head of Division of  Clinical Pharmacolog...
Organization Chart (2)                                Adverse Drug                                  Reaction              ...
Organization Chart (3)• 11 Fellows• 6-8 Graduate students• 10 Counselors
Organization Chart (4)• Case Round (Shinya’s Round)• Fellow’s Lecture• Review Round (Gidi’s Round)• Breast Feeding Round• ...
Motherisk Program(Call Center and Clinic)
Motherisk Program (Call Center) (1)                          1             MR General                Line                 ...
Motherisk Program (Call Center) (2)                    Total                 number of                call: 34,558        ...
Motherisk Program (Call Center) (3)   Caller Type     Number of Questions per Call                   on the MR General Lin...
The Most Called About Exposures during Pregnancyon the Motherisk General Line Frequency of Question (%)                   ...
The Most Called About Exposures during Lactation onthe Motherisk General Line   Frequency of Question (%)                 ...
Motherisk Clinic (1)• Every Friday Afternoon• Conducted by Fellow & Staff
Motherisk Clinic (2)          Reasons for Clinic Visit  Frequency of Question (%)                                         ...
Motherisk Clinic (3)   Return Mail
Laboratory Studies in Motherisk              Hair Test
Hair Test (1)
Hair Test (1)                                                                     AlcoholFAEE concentration       Classifi...
Hair Test (2)                                Methamphetamine• Half of a million people using this drug  weekly in the USA•...
Hair Test (3)                                                      Drugs in Adult Hair                         COCAINE    ...
Laboratory Studies in Motherisk        Placental Perfusion Study
Placental Perfusion Study (1)• Human placental perfusion, first  designed by Schneider et al (1972)• To investigate drug t...
Placental Perfusion Study (2)• Exclusion Criteria - Preterm placenta - Extremely fibrotic changed placenta - Many defects ...
Studies in Canada  Fetal outcomes in women taking domperidone               during pregnancyJune-Seek Choi,*,† Jung-Yeol H...
Fetal outcomes in women taking domperidone during                    pregnancy                                            ...
Studies in Canada     Pregnancy and isotretinoin therapy        June Seek Choi, Gideon Koren, Irena Nulman
Pregnancy and isotretinoin therapy• Oral isotretinoin was introduced in the USA  in 1982 and Canada in 1983.• 20-35% risk ...
Pregnancy and isotretinoin therapyPregnancy Preventio        System to Manage Accu             iPLEDGEn Program(PPP)      ...
Pregnancy and isotretinoin therapy
Pregnancy and isotretinoin therapy• We propose that every physician and pharmacist  who prescribes or dispenses isotretino...
Studies in CanadaFetal and neonatal outcomes in women reportingingestion of licorice (Glycyrrhiza uralensis) during       ...
Fetal and neonatal outcomes in women reporting ingestion of       licorice (Glycyrrhiza uralensis) during pregnancy• The r...
Fetal and neonatal outcomes in women reporting ingestion of        licorice (Glycyrrhiza uralensis) during pregnancy      ...
Fetal and neonatal outcomes in women reporting ingestion of       licorice (Glycyrrhiza uralensis) during pregnancy• The r...
Fetal and neonatal outcomes in women reporting ingestion of       licorice (Glycyrrhiza uralensis) during pregnancy25th In...
Studies in CanadaFetal and neonatal outcomes in pregnant women exposed to  abdominal or lumbar radiodiagnostic procedures ...
Fetal and neonatal outcomes in pregnant women exposed to abdominal or       lumbar radiodiagnostic procedures without admi...
Fetal and neonatal outcomes in pregnant women exposed to abdominal or        lumbar radiodiagnostic procedures without adm...
Future Works• Paper for Individual Herbal Medicine• Establish Placental Perfusion Study  in Korean Motherisk Program• Impr...
Thank you for your attention!!
Elementswww.animationfactory.com
캐나다 마더리스크프로그램연수기 - 최준식 교수
캐나다 마더리스크프로그램연수기 - 최준식 교수
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캐나다 마더리스크프로그램연수기 - 최준식 교수

  1. 1. Motherisk Program in Canada June Seek Choi, M.D., PhD. The Korean Motherisk Program, Div. of Maternal-Fetal Medicine, Dept. of OB & GYN, Cheil General Hospital and Women’s Healthcare Center, Kwandong University School of Medicine
  2. 2. The Hospital for Sick Children
  3. 3. The Hospital for Sick Children
  4. 4. The Hospital for Sick Children
  5. 5. Contents• Organization Chart• Motherisk Program (Clinic and Call Center)• Laboratory Studies in Motherisk• Studies in Canada
  6. 6. Organization Chart
  7. 7. Organization Chart (1)• Dr. Gideon Koren- Director of Motherisk• Dr. Ito Shinya- Head of Division of Clinical Pharmacology & Toxicology• Dr. Irena Nulman- Associate Director of Motherisk, Alcohol & Drugs in Pregnancy
  8. 8. Organization Chart (2) Adverse Drug Reaction Clinical Pharmacology & Toxicology Breast Feeding Sickkids Motherisk Call Hospital Center Clinic Motherisk Program Placental Study Hair Test
  9. 9. Organization Chart (3)• 11 Fellows• 6-8 Graduate students• 10 Counselors
  10. 10. Organization Chart (4)• Case Round (Shinya’s Round)• Fellow’s Lecture• Review Round (Gidi’s Round)• Breast Feeding Round• Clinical Pharmacology Tutorial• Toxicology Round• Pre-clinic Meeting• Motherisk Round• Motherisk Clinic
  11. 11. Motherisk Program(Call Center and Clinic)
  12. 12. Motherisk Program (Call Center) (1) 1 MR General Line 2 Motherisk Helpline Alcohol 1 Line NVP Line 1
  13. 13. Motherisk Program (Call Center) (2) Total number of call: 34,558 Alcohol and MR general NVP line: Substance line: 31,206 2,035 use: 1,317 Motherisk 2011
  14. 14. Motherisk Program (Call Center) (3) Caller Type Number of Questions per Call on the MR General Line Motherisk 2011
  15. 15. The Most Called About Exposures during Pregnancyon the Motherisk General Line Frequency of Question (%) Motherisk 2011
  16. 16. The Most Called About Exposures during Lactation onthe Motherisk General Line Frequency of Question (%) Motherisk 2011
  17. 17. Motherisk Clinic (1)• Every Friday Afternoon• Conducted by Fellow & Staff
  18. 18. Motherisk Clinic (2) Reasons for Clinic Visit Frequency of Question (%) Motherisk 2011
  19. 19. Motherisk Clinic (3) Return Mail
  20. 20. Laboratory Studies in Motherisk Hair Test
  21. 21. Hair Test (1)
  22. 22. Hair Test (1) AlcoholFAEE concentration Classification Interpretation> 1.0 ng/mg (positive) Chronic Alcohol -100% specific for regular, excessive alcohol Abuser consumption -25% of chronic alcohol abusers will test below this level0.50-0.99 ng/mg Chronic Alcohol -90% specific for regular, excessive alcohol(positive) Abuser consumption -10% of chronic alcohol abusers will test below this range -10% of moderate drinkers will show result in this range< 0.49 ng/mg Moderate/Non-drinker -No evidence of excessive alcohol consumption(negative) (Up to 20g of alcohol per day; ~2drinks)< 0.20 – 0.040 ng/mg Non-Drinker (abstainer) -No evidence of alcohol consumption(negative) The Hospital for Sick Children 2007
  23. 23. Hair Test (2) Methamphetamine• Half of a million people using this drug weekly in the USA• 8% of individuals with positive drug test in Motherisk database are positive for methamphetamine• 85% of the individuals positive for methamphetamine are positive for at least one other drug abuse, most commonly cocaine
  24. 24. Hair Test (3) Drugs in Adult Hair COCAINE OPIATES CANNABIS AMPETAMINE METHAMPHETAMINE ng/mg ng/mg ng/mg ng/mg ng/mg (n = 1,532) (n = 426) (n = 597) (n = 97) (n =243)median 2.38 0.65 0.33 0.60 1.03VERY LOW < 0.23 < 0.16 < 0.11 < 0.13 < 0.16(5th percentile)LOW 0.23-0.71 0.16-0.33 0.11-0.18 0.13-0.30 0.16-0.37(5-25th percentile)MEDIUM 0.72-8.58 0.34-1.77 0.19-0.70 0.31-1.44 0.38-3.87(25-75th percentile)HIGH 8.59-39.47 1.78-8.22 0.71-2.86 1.45-9.72 3.88-24.51(75-95th percentile)VERY HIGH > 39.47 > 8.22 > 2.86 > 9.72 > 24.51(95th percentile) The Hospital for Sick Children 2006
  25. 25. Laboratory Studies in Motherisk Placental Perfusion Study
  26. 26. Placental Perfusion Study (1)• Human placental perfusion, first designed by Schneider et al (1972)• To investigate drug transfer from the maternal to the fetal circulation• Placental perfusion study has been conducted in Motherisk since 2004
  27. 27. Placental Perfusion Study (2)• Exclusion Criteria - Preterm placenta - Extremely fibrotic changed placenta - Many defects in cotyledon - Hepatitis, HIV• Failure Rate: 90%
  28. 28. Studies in Canada Fetal outcomes in women taking domperidone during pregnancyJune-Seek Choi,*,† Jung-Yeol Han,*,† Hyun-Kyong Ahn,*,† Hyun-Mee RYU,†Moon-Young KIM,† Jae-Hyug YANG,† Alejandro A. Nava-Ocampo‡,§ and Gideon Koren¶
  29. 29. Fetal outcomes in women taking domperidone during pregnancy Cases (n= 120) Controls (n=212) 95% CI for the difference P valueGestational age at birth (weeks) 39.1 ± 1.4 39.2 ± 2.0 -0.5, 0.4 0.81Birth weight (g) 3,308.4 ± 529.1 3,273.0 ± 485.0 -77.2, 148.1 0.54Birth length (cm) 49.5 ± 2.5 46.6 ± 2.2 -0.7, 1.4 0.51Head circumference at birth (cm) 34.4 ± 3.7 34.2 ± 3.8 -0.6, 1.6 0.58Apgar score, 1 min 8.3 ± 1.3 8.2 ± 1.3 -0.2, 0.2 0.80Apgar score, 5 min 9.0 ± 1.3 8.9 ± 1.4 -0.1, 0.3 0.36Malformationsa 3 (2.5) 3 (1.4) OR= 0.6 (0.1, 2.8) 0.38Meconium staining at birth - 1 (0.5) - 0.69Neonatal jaundice 1 (0.8%) 4 (1.9) OR= 2.3 (0.3, 20.7) 0.41aIn the case group: a baby born with bilateral equino varus and right calcaneal deformity, another with megacisterna magna, and athird one with right inguinal hernia.In the control group: a baby born with skin tag on the left nipple and a spot on left knee, another with left dysplastic kidney, and a thirdone with left pyelectasis
  30. 30. Studies in Canada Pregnancy and isotretinoin therapy June Seek Choi, Gideon Koren, Irena Nulman
  31. 31. Pregnancy and isotretinoin therapy• Oral isotretinoin was introduced in the USA in 1982 and Canada in 1983.• 20-35% risk for congenital defects 232 types of generic (craniofacial, central nervous system, and original cardiovascular, and thymic malformations) isotretinoin made in 36 countries around• 30-60% of children prenatally exposed to the world isotretinoin have been reported to demonstrate neurocognitive impairment, even without physical defects.
  32. 32. Pregnancy and isotretinoin therapyPregnancy Preventio System to Manage Accu iPLEDGEn Program(PPP) tane Related Teratogeni city (SMART) • 1988 • 2002 • 2006 • 34% failing to receive the • Monthly pregnancy tes • 36% failed to required two pregnancy ts, tests before beginning • Documentation of receive a treatment contraceptive use, pregnancy test • 54% of women of child- • Patient education bearing age failing to use reinforcing key safety two methods of birth- messages control • Registered in a single database
  33. 33. Pregnancy and isotretinoin therapy
  34. 34. Pregnancy and isotretinoin therapy• We propose that every physician and pharmacist who prescribes or dispenses isotretinoin should complete a mandatory online certification program involving proper education about contraceptive methods and the therapeutic and fetotoxic effects of this drug.• With improved education of patients and healthcare providers, improved patient adherence with established safety protocols, and proper control of isotretinoin distribution, one can hope that more women will use isotretinoin safely.
  35. 35. Studies in CanadaFetal and neonatal outcomes in women reportingingestion of licorice (Glycyrrhiza uralensis) during pregnancyJune-Seek Choi1,2, Jung-Yeol Han1,2, Hyun-Kyeong Ahn1,2, Hyun-Mee Ryu2,Moon-Young Kim2, Jin-Hoon Chung2, Alejandro A. Nava-Ocampo3,4,5, Gideon Koren4,5,6
  36. 36. Fetal and neonatal outcomes in women reporting ingestion of licorice (Glycyrrhiza uralensis) during pregnancy• The roots and rhizomes of licorice species have long been used worldwide as a natural remedy and sweetener in candies, liquor, and teas.• A large number of chemicals has been isolated from licorice, including triterpene saponins, flavonoids, isoflavonoids and chalcones, and glycyrrhizin, the latter of which is considered to be the main biologically active component of licorice.• In Republic of Korea, licorice is present in over 2,000 OTC formulations, and in more than 200 galenic formulations.
  37. 37. Fetal and neonatal outcomes in women reporting ingestion of licorice (Glycyrrhiza uralensis) during pregnancy Cases (n= 180) Controls (n= 350) 95% CI for the difference P valueStillbirths, n (%) 4 (2.2) 1 (0.3) OR= 7.9 (0.9 to 71.5) 0.048Live births, n (%) 176 (97.8) 349 (99.7) OR= 0.1 (0.0 to 1.1) 0.048Preterm births, n (%) 17 (9.4) 22 (6.3) OR= 1.5 (0.8 to 3.0) 0.19Gestational age (weeks; mean ± SD) 39.0 ± 2.5 39.3 ± 1.7 -0.007, 0.7 0.05Birth weight (g; mean ± SD) 3,294.1 ± 522.0 3,287.9 ± 457.6 -93.0., 80.5 0.89Birth length (cm; mean ± SD) 49.7 ± 2.3 49.6 ± 1.9 -0.5, 0.3 0.60Head circumference (cm; mean ± 34.6 ± 1.5 34.5 ± 1.3 -0.3, 0.2 0.62SD)Apgar score, 1 min (mean ± SD) 8.4 ± 0.9 8.6 ± 3.9 -0.4, 0.8 0.45Apgar score, 5 min (mean ± SD) 9.0 ± 0.7 9.1 ± 0.9 -0.4, 0.8 0.37Major malformations, n (%) 2 (1.1)a 1 (0.3)b OR= 3.9 (0.4 to 43.5) 0.27Minor malformations, n (%) - 2 (0.6)c - 0.44Meconium staining at birth, n (%) - 5 (1.4) - 0.13Neonatal jaundice, n (%) 3 (1.7) 8 (2.3) OR= 0.7 (0.2 to 2.8) 0.46aA baby born with megacisterna magna, and another born with dysplastic changes in the left kidney, left ectopic ureteral insertion, and hydroureter andmild pyelectasis in the right kidney.bA baby born with mild forefoot adduction, varus deformity of left foot and calcaneal deformity of right foot, and is being followed up by a pediatric orthopedist.cA baby born with a single umbilical artery, and another baby born with left pyelectasis
  38. 38. Fetal and neonatal outcomes in women reporting ingestion of licorice (Glycyrrhiza uralensis) during pregnancy• The rate of stillbirths was marginally higher among women who took licorice than those who did not (OR= 7.9; 95%CI 0.9-71.5; P=0.048), and significantly higher when compared to the general population in Republic of Korea (OR= 13.3; 95% CI 4.9-35.8; P<0.001).
  39. 39. Fetal and neonatal outcomes in women reporting ingestion of licorice (Glycyrrhiza uralensis) during pregnancy25th International Conference of the Organization ofTeratology Information SpecialistsMarriott Baltimore Waterfront
  40. 40. Studies in CanadaFetal and neonatal outcomes in pregnant women exposed to abdominal or lumbar radiodiagnostic procedures without administration of radionucleotidesJune-Seek Choi1,2, Jung-Yeol Han1,2, Hyun-Kyeong Ahn1,2, Hyun-Mee Ryu2,Moon-Young Kim2, Jin-Hoon Chung2, Gye-Hyeong An2, and Alejandro A. Nava-Ocampo3,4,5
  41. 41. Fetal and neonatal outcomes in pregnant women exposed to abdominal or lumbar radiodiagnostic procedures without administration of radionucleotides Characteristics n (%) A) Radiological study Lumbar spine radiography 40 (34.5) Plain abdominal radiography 19 (16.4) Upper gastrointestinal tract radiography 18 (15.5) Abdominal CT scan without contrast 13 (11.2) Contrast-enhanced abdominal CT scan 6 (5.2) Urinary tract X-ray 6 (5.2) Barium enema 5 (4.3) Pelvis radiography 5 (4.3) Intravenous pyelogram 2 (1.7) Lumbar CT scan 2 (1.7) B) Indications Low back pain 33 (28.4) Check-up 32 (27.6) Abdominal pain 16 (13.8) Functional gastrointestinal disorders 15 (12.9) Evaluation post-car accident 10 (8.6) n= 115 Upper respiratory tract infection 1 (0.9) aBased on the estimates for selected procedures published elsewhere10 Others 9 (7.8) 1 mSv = 1 mGy = 0.1 rad bMedian (ranges) C) Fetal dose (mSv)a 7.2 (0.3 – 66.6)b
  42. 42. Fetal and neonatal outcomes in pregnant women exposed to abdominal or lumbar radiodiagnostic procedures without administration of radionucleotidesFetal and neonatal outcomes Exposed (n= 105) Controls (n= 485) 95% CI for the difference P valueGestational age at birth (weeks) 39.5 ± 1.1 39.2 ± 1.6 -0.6, 0.1 0.13Birth weight (g) 3,321.2 ± 422.6 3,300.6 ± 428.7 -111.5., 70.1 0.66Birth length (cm) 49.5 ± 2.6 49.5 ± 1.9 -0.5, 0.4 0.96Head circumference at birth (cm) 34.7 ± 1.9 34.6 ± 1.7 -0.4, 0.3 0.831-min Apgar score 8.4 ± 0.6 8.3 ± 0.8 -0.3, 0.1 0.305-min Apgar score 9.0 ± 0.6 9.1 ± 0.7 -0.1, 0.2 0.41IUFD (%) 1 (1.0) 1 (0.2) OR= 4.7 (0.3, 75.0) 0.33Malformationsa (%) 2 (1.9) 2 (0.4) OR= 4.7 (0.7, 33.6) 0.15NICU admission (%) 5 (4.8) 8 (1.7) OR= 2.9 (1.0, 9.3) 0.062Duration at NICU (days) 6.0 ± 3.0 6.3 ± 7.4 -10.2, 10.8 0.95Meconium stain at birth (%) - 2 (0.4) - 0.68Neonatal jaundice (%) 2 (1.9) 11 (2.3) OR= 0.8 (0.2, 3.8) 0.59aInthe case group: a baby born with left cerebral mild ventriculomegaly and infantile spasm, second one with small pulmonary artery. In the control group: ababy born with cleft palate, second one with mega cistern magna.
  43. 43. Future Works• Paper for Individual Herbal Medicine• Establish Placental Perfusion Study in Korean Motherisk Program• Improvement of Korean Motherisk Database
  44. 44. Thank you for your attention!!
  45. 45. Elementswww.animationfactory.com

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