Maternal Outcomes of Ongoing Pregnancies Complicated by Fetal Life-Limiting Conditions

OBJECTIVE

This study aimed to examine maternal outcomes of ongoing pregnancies complicated by fetal life-limiting conditions.

STUDY DESIGN

This was a retrospective matched cohort study of women with a diagnosis of fetal life-limiting condition between 2010 and 2018 in a single academic center. Cases were matched to controls (women who had normal fetal anatomic survey) according to year of delivery, body mass index, and parity in a 1:4 ratio. Bivariable and multivariable analyses were performed to compare the prevalence of the primary composite outcome, which included any one of the following: preeclampsia, gestational diabetes, cesarean delivery, third and fourth degree laceration, postpartum hemorrhage, blood transfusion, endometritis or wound infection, maternal intensive care unit admission, hysterectomy and maternal death, between cases and controls.

RESULTS

During the study period, we found 101 cases that met inclusion criteria, matched to 404 controls. The rate of the composite maternal outcome did not differ between the two groups (39.6 vs. 38.9%, p = 0.948). For individual outcomes, women with diagnosis of fetal life-limiting condition had higher rates of blood transfusion (2.0 vs. 0%, p = 0.005) and longer length of the first stage of labor (median of 12 [6.8-22.0] hours vs. 6.6 [3.9-11.0] hours; p < 0.001). In a multivariable analysis, first stage of labor continued to be longer by an average of 6.48 hours among women with a diagnosis of fetal life-limiting condition compared with controls.

CONCLUSION

After controlling for confounding factors, except a longer first stage of labor, women diagnosed with fetal life-limiting conditions who continued the pregnancy did not have a higher rate of adverse maternal outcomes.

KEY POINTS

· The rates of ongoing pregnancies with fetal life-limiting conditions are increasing.. · Women with ongoing pregnancies with fetal life-limiting conditions had longer first stage of labor.. · The rest of the adverse maternal outcomes were not increased in this obstetric population..

Occupational therapy, loneliness and social isolation: a thematic review of the literature

Background/Aims

Loneliness and social isolation are thought to have a negative impact on health and wellbeing. There is little literature that provides an explicit focus on loneliness and social isolation in occupational therapy practice. The aim of this study was to explore themes related to loneliness and social isolation in occupational therapy-related literature and consider the implications for practice.

Methods

CINAHL, Medline, Pub Med, AMed, PsycINFO, TRIP Database, and Science direct and Web of science databases were used to identify articles pertaining to occupational therapy, loneliness and social isolation.

Results

A total of 20 articles were included and three themes were identified: loneliness and social isolation are detrimental to health and wellbeing; factors associated with increased loneliness and social isolation; factors that protect against the impact of loneliness and social isolation.

Conclusions

Loneliness and social isolation have a significant impact on the health and wellbeing of the people occupational therapists work with. Occupational therapy practice should include the recognition and assessment of loneliness and social isolation, and interventions to help reduce any impacts on health and wellbeing.

An investigation of the effects of walking frame height and width on walking stability

BACKGROUND

Walking aids are designed for structural support during walking, however, surprisingly self-reported use of a walking aid ("Yes, I use one.") has been identified as a risk factor for falling. Adjustment and design of walking aids may affect their usefulness in facilitating a stable walking pattern. We previously identified that increased body weight transfer onto a walking frame ('device loading') is associated with increased user stability.

RESEARCH QUESTION

We asked: "Could adjustment of walking frame height to a lower height than clinically recommended serve as a mechanism to facilitate device loading and thereby increase stability? And: "Do ultra-narrow frames have an adverse effect on stability as compared to standard-width frames?

METHODS

Ten older adults that were users of front-wheeled walking frames walked with walking frames of 1) 'standard width, standard height', 2)'standard width, low height', 3)'narrow width, standard height'. Smart Walker technology was used to record forces acting on the walking frame and inside the user's shoes, and cameras recorded relative position of the user's feet in relation to the frame's feet. Stability of the user-frame system and device loading (percent body weight transferred onto the frame) were calculated. A general linear mixed effects model was used for statistical analysis.

RESULTS

A lower height setting did not increase device loading and stability, therefore adjusting the height to a lower setting proved to be an unsuccessful mechanism to increase stability. However, device loading was positively correlated with stability for all frame conditions (p < 0.05). Finally, stability was reduced when walking with the ultra-narrow, as compared to standard-width, frame (p = 0.002).

SIGNIFICANCE

To increase stability in fall-prone users, active encouragement to transfer body weight onto the walking frame is needed. Considering the adverse effects of ultra-narrow frames on stability, such frames should be prescribed and used with caution.

Final results for the neutron -asymmetry parameter A0 from the UCNA experiment

The UCNA experiment was designed to measure the neutron β-asymmetry parameter A0 using polarized ultracold neutrons (UCN). UCN produced via downscattering in solid deuterium were polarized via transport through a 7 T magnetic field, and then directed to a 1 T solenoidal electron spectrometer, where the decay electrons were detected in electron detector packages located on the two ends of the spectrometer. A value for A0 was then extracted from the asymmetry in the numbers of counts in the two detector packages. We summarize all of the results from the UCNA experiment, obtained during run periods in 2007, 2008–2009, 2010, and 2011–2013, which ultimately culminated in a 0.67% precision result for A0.

Cligosiban, A Novel Brain-Penetrant, Selective Oxytocin Receptor Antagonist, Inhibits Ejaculatory Physiology in Rodents

INTRODUCTION

Few treatments are available for men with premature ejaculation (PE); oxytocin (OT) receptor antagonism in the central nervous system (CNS) is a potential new approach.

AIM

To determine if cligosiban selectively inhibits human OT receptors, penetrates the CNS, shows pharmacology in the CNS, and effects ejaculatory physiology in pre-clinical systems.

METHODS

Experiments complied with United Kingdom legislation and were subject to local ethical review. In vitro potency and selectivity of cligosiban was assessed using recombinant and native OT receptor systems including both neuronal and non-neuronal cell types. Selectivity was determined over neighboring V_1A, V_1B, and V₂ vasopressin receptors using a combination of recombinant and native vasopressin receptor assay systems. To determine an effect on central OT receptors and on ejaculation, cligosiban was evaluated in 2 anesthetized rat models-the electromyography model of ejaculatory physiology and a model of OT-mediated CNS neuronal firing. The CNS penetration of cligosiban was also determined by measuring cerebrospinal fluid and plasma drug concentrations following an intravenous (IV) infusion in rats.

MAIN OUTCOME MEASURE

These were functional measures of pharmacology in vitro, in cell lines and tissues, and in vivo in rats.

RESULTS

Cligosiban is a potent OT receptor antagonist, with a base dissociation constant of 5.7 nmol/L against native human uterine smooth muscle cell OT receptors. Cligosiban displays similar antagonistic potency against human recombinant and rat native OT receptors, including neuronal OT receptors. Cligosiban demonstrates >100-fold selectivity over human V_1A, V_1B, and V₂ vasopressin receptors. In the electromyography model, cligosiban (0.9 mg/kg, IV bolus) reduced the bulbospongiosum burst pattern and contraction amplitude associated with ejaculation. In the anesthetized CNS neuronal firing model, the same dosing regimen of cligosiban (0.9 mg/kg IV bolus) modulated the OT-mediated response in the nucleus tractus solitarius. After systemic dosing to rats, cligosiban showed good CNS penetration.

CLINICAL IMPLICATIONS

As the first highly selective and centrally penetrant OT receptor antagonist, cligosiban represents a promising compound to test the clinical hypothesis that antagonism of central OT receptors may be of therapeutic benefit in the treatment of PE.

STRENGTH & LIMITATIONS

The pharmacology and selectivity of cligosiban is determined using functional assays in recombinant cell lines, native cell lines, and tissue. Functional outcomes in in vivo systems are linked to CNS measures of pharmacology. The translation of the animal models of ejaculation to PE in man is unproven.

CONCLUSION

Cligosiban, a potent, selective OT receptor antagonist, demonstrated CNS penetration and pharmacology and, using the same dosing regimen, inhibited apomorphine-induced ejaculation in rats. Cligosiban is a promising compound to test the clinical hypothesis that antagonism of central OT receptors may be of therapeutic benefit in the treatment of PE. Wayman C, Russell R, Tang K, et al. Cligosiban, A Novel Brain Penetrant Selective Oxytocin Receptor Antagonist, Inhibits Ejaculatory Physiology in Rodents. J Sex Med 2018;15:1698-1706.

Progesterone Application to the Rat Forehead Produces Corneal Antinociception

Purpose

Ocular pain and discomfort are the most defining symptoms of dry eye disease. We determined the ability of topical progesterone to affect corneal sensitivity and brainstem processing of nociceptive inputs.

Methods

Progesterone or vehicle gel was applied to the shaved forehead in male Sprague Dawley rats. As a site control, gel also was applied to the cheek on the side contralateral to corneal stimulation. Corneal mechanical thresholds were determined using the Cochet-Bonnet esthesiometer in intact and lacrimal gland excision–induced dry eye animals. Eye wipe behaviors in response to hypertonic saline and capsaicin were examined, and corneal mustard oil-induced c-Fos immunohistochemistry was quantified in the brainstem spinal trigeminal nucleus.

Results

Progesterone gel application to the forehead, but not the contralateral cheek, increased corneal mechanical thresholds in intact and lacrimal gland excision animals beginning <30 minutes after treatment. Subcutaneous injection of the local anesthetic bupivacaine into the forehead region before application of progesterone prevented the increase in corneal mechanical thresholds. Furthermore, progesterone decreased capsaicin-evoked eye wipe behavior in intact animals and hypertonic saline evoked eye wipe behavior in dry eye animals. The number of Fos-positive neurons located in the caudal region of the spinal trigeminal nucleus after corneal mustard oil application was reduced in progesterone-treated animals.

Conclusions

Results from this study indicate that progesterone, when applied to the forehead, produces analgesia as indicated by increased corneal mechanical thresholds and decreased nociceptive responses to hypertonic saline and capsaicin.

Osteoarthritis in England: Incidence Trends From National Health Service Hospital Episode Statistics

Objective

It is typical in epidemiological research of osteoarthritis (OA) to collect data for the hand, hip, and knee. However, little population‐based data exist for this disease in the foot. Thus, we addressed patterns of OA for the foot compared with the hand, hip, and knee spanning 2000/2001 to 2017/2018 in England.

Methods

Secondary‐care data from 3 143 928 patients with OA of the foot, hand, hip, and knee were derived from the National Health Service (NHS) Hospital Episode Statistics (HES) database. Distribution, population prevalence, and incidence of joint‐specific OA were stratified by age and sex.

Results

OA incidence increased significantly at the foot [3.8% (95% confidence interval [CI] 3.0, 4.6)], hand [10.9% (10.1, 11.7)], hip [3.8% (2.9, 4.7)], and knee [2.9% (2.2, 3.6)] per year from 2000/2001 to 2017/2018. A higher proportion of women were diagnosed with OA, whereas greater incidence in men was estimated for the hand and hip. Foot OA presented comparable diagnosis numbers to the hand. More recently during 2012/2013 to 2017/2018, a significant rise in hip OA was estimated among younger adults, whereas knee OA decreased across all age groups. Incidence of OA in the foot and hand were particularly significant among the 75 or older age group, though bimodal age distributions were observed for both sites.

Conclusion

The significant increase in secondary care records for OA in England underscores the importance of exploring possible causative factors and identifying groups most at risk. Further detailed data may be particularly important for the hip, which represents significant incidence among younger adults. Greater incidence of OA in the foot compared with the knee emphasizes the need for well‐conducted epidemiological research in this area. Monitoring the performance of surgical outcomes at the population‐level for this frequently affected yet understudied site could have substantial potential to reduce the socioeconomic burden it represents to the NHS.

Treatment of obstetric post-dural puncture headache. Part 2: epidural blood patch

The 2009-12 MBRRACE-UK report highlighted the deaths of two women in whom dural puncture had occurred during insertion of a labour epidural catheter. Despite suffering long-term headaches, neither woman was adequately followed-up after discharge from hospital. Death resulted from a cerebral vein thrombosis in one case and a subdural haematoma in the other. Due to significant variation in the treatment of obstetric post-dural puncture headache, an Obstetric Anaesthetists' Association working group was set up to produce evidence-based guidelines to guide clinicians. These guidelines have been condensed into two review articles. In this second review, the role of an epidural blood patch is discussed using a question and answer format.

Learning from the transfer of a fellowship programme to support primary care workforce needs in the UK: a qualitative study

OBJECTIVES

Service redesign, including workforce development, is being championed by UK health service policy. It is allowing new opportunities to enhance the roles of staff and encourage multiprofessional portfolio working. New models of working are emerging, but there has been little research into how innovative programmes are transferred to and taken up by different areas. This study investigates the transferability of a 1-year post-Certification of Completion of Training fellowship in urgent and acute care from a pilot in the West Midlands region of England to London and the South East.

DESIGN

A qualitative study using semistructured interviews supplemented by observational data of fellows' clinical and academic activities. Data were analysed using a thematic framework approach.

SETTING AND PARTICIPANTS

Two cohorts of fellows (15 in total) along with key stakeholders, mentors, tutors and host organisations in London and the South East (LaSE). Fellows had placements in primary and secondary care settings (general practice, emergency department, ambulatory care, urgent care and rapid response teams), together with academic training.

RESULTS

Seventy-six interviews were completed with 50 participants, with observations in eight clinical placements and two academic sessions. The overall structure of the West Midlands programme was retained and the core learning outcomes adopted in LaSE. Three fundamental adaptations were evident: broadening the programme to include multiprofessional fellows, changes to the funding model and the impact that had on clinical placements. These were felt to be key to its adoption and longer-term sustainability.

CONCLUSION

The evaluation demonstrates a model of training that is adaptable and transferable between National Health Service regions, taking account of changing national and regional circumstances, and has the potential to be rolled out widely.

Influence of Community-Level Cultural Beliefs about Autism on Families' and Professionals' Care for Children

This qualitative study aimed to understand how community-level cultural beliefs affect families' and professionals' care for children with autism and developmental delays in immigrant communities, as a first step towards promoting early identification and access to early intervention services. The study was part of the larger New York City (NYC) Korean Community Autism Project, which was designed to identify strategies to increase awareness of autism and reduce delays in treatment seeking within the NYC Korean-American community. Our study elicited early childcare workers' and church leaders' beliefs about autism and developmental disorders and, in particular, early intervention. We also elicited responses to newly developed outreach materials targeting this community. An inductive approach was used to identify concepts and categories associated with autism. Our study confirmed that discomfort, stigma and discrimination are the prevailing community attitudes toward autism and developmental disorders in the Korean-American community. Families' and professionals' understanding of autism and their care for children are affected by these community beliefs. Approaching immigrant communities with general information about child development and education rather than directly talking about autism and developmental disorders is likely to engage more families and professionals in need for diagnostic evaluation and early intervention for autism.

Associations between genomic stratification of breast cancer and centrally reviewed tumour pathology in the METABRIC cohort

The integration of genomic and transcriptomic profiles of 2000 breast tumours from the METABRIC [Molecular Taxonomy of Breast Cancer International Consortium] cohort revealed ten subtypes, termed integrative clusters (IntClust/s), characterised by distinct genomic drivers. Central histopathology (N = 1643) review was undertaken to explore the relationship between these ten molecular subtypes and traditional clinicopathological features. IntClust subtypes were significantly associated with histological type, tumour grade, receptor status, and lymphocytic infiltration (p < 0.0001). Lymph node status and Nottingham Prognostic Index [NPI] categories were also significantly associated with IntClust subtype. IntClust 3 was enriched for tubular and lobular carcinomas, the latter largely accounting for the association with CDH1 mutations in this cluster. Mucinous carcinomas were not present in IntClusts 5 or 10, but did not show an association with any of the remaining IntClusts. In contrast, medullary-like cancers were associated with IntClust 10 (15/26). Hormone receptor-positive tumours were scattered across all IntClusts. IntClust 5 was dominated by HER2 positivity (127/151), including both hormone receptor-positive (60/72) and hormone receptor-negative tumours (67/77). Triple-negative tumours comprised the majority of IntClust 10 (132/159) and around a quarter of IntClust 4 (52/217). Whilst the ten IntClust subtypes of breast cancer show characteristic patterns of association with traditional clinicopathological variables, no IntClust can be adequately identified by these variables alone. Hence, the addition of genomic stratification has the potential to enhance the biological relevance of the current clinical evaluation and facilitate genome-guided therapeutic strategies.

Factors influencing career intentions on completion of general practice vocational training in England: a cross-sectional study

OBJECTIVES

General practice is experiencing a growing crisis with the numbers of doctors who are training and then entering the profession in the UK failing to keep pace with workforce needs. This study investigated the immediate to medium term career intentions of those who are about to become general practitioners (GPs) and the factors that are influencing career plans.

DESIGN

Online questionnaire survey, with quantitative answers analysed using descriptive statistics and free text data analysed using a thematic framework approach.

SETTING AND PARTICIPANTS

Doctors approaching the end of 3-year GP vocational training in the West Midlands, England.

RESULTS

178 (57.2%) doctors completed the survey. Most participants planned to work as salaried GPs or locums rather than entering a general practice partnership for at least the first 5 years post-completion of training; others failed to express a career plan or planned to leave general practice completely or work overseas. Many were interested in developing portfolio careers.The quality of general practice experience across undergraduate, foundation and vocational training were reported as influencing personal career plans, and in particular perceptions about workload pressure and morale within the training practices in which they had been placed. Experience of a poor work-life balance as a trainee had a negative effect on career intentions, as did negative perceptions about how general practice is portrayed by politicians and the media.

CONCLUSION

This study describes a number of potentially modifiable factors related to training programmes that are detrimentally influencing the career plans of newly trained GPs. In addition, there are sociodemographic factors, such as age, gender and having children, which are also influencing career plans and so need to be accommodated. With ever-increasing workload in general practice, there is an urgent need to understand and where possible address these issues at national and local level.

Challenges of modern day transition care in inflammatory bowel disease: From inflammatory bowel disease to biosimilars

In this article we discuss the challenges of delivering a high quality Transition care. A good understanding of the adolescent needs with good communication between Transition care physicians and the patient is essential for good continuity of care. Despite availability of several guidelines, one model doesn’t fit all and any transition service development should be determined by the local need and available healthcare facilities.